J Korean Med Sci.  2024 Sep;39(35):e242. 10.3346/jkms.2024.39.e242.

Public and Clinician Perspectives on Ventilator Withdrawal in Vegetative State Following Severe Acute Brain Injury: A Vignette Survey

• Yoo SH
• Lee J
• Song IG
• Jeon SY
• Kim MS
• Park HY

• KMID: 2559195
• DOI: http://doi.org/10.3346/jkms.2024.39.e242

Abstract

Background
The vegetative state (VS) after severe acute brain injury (SABI) is associated with significant prognostic uncertainty and poor long-term functional outcomes. However, it is generally distinguished from imminent death and is exempt from the Life-Sustaining Treatment (LST) Decisions Act in Korea. Here, we aimed to examine the perspectives of the general population (GP) and clinicians regarding decisions on mechanical ventilator withdrawal in patients in a VS after SABI.
Methods
A cross-sectional survey was undertaken, utilizing a self-reported online questionnaire based on a case vignette. Nationally selected by quota sampling, the GP comprised 500 individuals aged 20 to 69 years. There were 200 doctors from a tertiary university hospital in the clinician sample. Participants were asked what they thought about mechanical ventilator withdrawal in patients in VS 2 months and 3 years after SABI.
Results
Two months after SABI in the case, 79% of the GP and 83.5% of clinicians had positive attitudes toward mechanical ventilator withdrawal. In the GP, attitudes were associated with spirituality, household income, religion, the number of household members. On the other hand, clinicians’ attitudes were related to their experience of completing advance directives (AD) and making decisions about LST. In this case, 3 years after SABI, 92% of the GP and 94% of clinicians were more accepting of ventilator withdrawal compared to previous responses, based on the assumption that the patient had written AD. However, it appeared that the proportion of positive responses to ventilator withdrawal decreased when the patients had only verbal expressions (82% of the GP; 75.5% of clinicians) or had not previously expressed an opinion regarding LST (58% of the GP; 39.5% of clinicians).
Conclusion
More than three quarters of both the GP and clinicians had positive opinions regarding ventilator withdrawal in patients in a VS after SABI, which was reinforced with time and the presence of AD. Legislative adjustments are needed to ensure that previous wishes for those patients are more respected and reflected in treatment decisions.

Keyword

Surveys and Questionnaires; Vegetative State; Brain Injuries; Mechanical Ventilator; Decision Making; Withdrawing Treatments; General Population; Clinicians

Figure

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  Fig. 1 Reason(s) for the response for withdrawal of mechanical ventilator 2 months after severe acute brain injury. (A) Reason(s) for acceptance with withdrawal. (B) Reason(s) for non-acceptance of withdrawal.*P < 0.05, **P < 0.01, ***P < 0.001.

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  Fig. 2 Differences in response to withdrawal of ventilator at each time point according to the patient’s intention on life-sustaining treatment between the general population and the clinicians.SABI = severe acute brain injury.***P < 0.001.

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  Fig. 3 Changes in response to ventilator withdrawal 3 years after severe acute brain injury in cases of verbal intention and no expressed opinions versus those with advance directives.

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