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Ethical considerations for performing decompressive craniectomy as a life-saving intervention for severe traumatic brain injury
  1. Stephen Honeybul1,
  2. Grant Gillett2,
  3. Kwok Ho3,
  4. Christopher Lind4
  1. 1Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Australia
  2. 2Bioethics Centre, Dunedin Hospital and Otago, University of Otago, Dunedin, Otago, New Zealand
  3. 3Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Perth, Western Australia, Australia
  4. 4School of Surgery, University of Western Australia, Perth, Western Australia, Australia
  1. Correspondence to Stephen Honeybul, Department of Neurosurgery, Sir Charles Gairdner Hospital, Hospital Avenue, Perth 6009, Australia; stephen.honeybul{at}


In all fields of clinical medicine, there is an increasing awareness that outcome must be assessed in terms of quality of life and cost effectiveness, rather than merely length of survival. This is especially the case when considering decompressive craniectomy for severe traumatic brain injury. The procedure itself is technically straightforward and involves temporarily removing a large section of the skull vault in order to provide extra space into which the injured brain can expand. A number of studies have demonstrated many patients going on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation. In an attempt to address these issues, we have used the analytical framework proposed by Jonsen, that requires systematic consideration of medical indications, patient preferences, quality of life and contextual features.

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