Seizure 2018, Vol 56, Editor’s Choice: Comparison of scoring tools for the prediction of in-hospital mortality in status epilepticus
There was a time when doctors considered themselves “gods in white” and behaved as such. Doctors knew best and told their patients what they should and shouldn’t do. Fortunately, the days when doctors (as well as patients and many working in allied health professions) did not feel the need to question this model of clinical decision-making are over. Of course, paternalistic patterns of doctor-patient communication persist, and the imbalance in knowledge and experience that underpins many medical decision-making processes is truly difficult to overcome, but in most circumstances (1), there is now an expectation that patients should participate in a collaborative process when important decisions are made about their treatment.
Having said that, there are some clinical scenarios when it is difficult or impossible to take patients’ own views into account. Decisions about the treatment of patients in refractory status epilepticus fall into this category. Doctors may be able to take account of patients’ advance directions or they may seek the views of family members about whether or not a patient would have wanted a particular treatment escalation. However, in most circumstances doctors will experience the now unaccustomed loneliness of a situation in which they have to decide what is in the patient’s best interest. Sometimes they will need to be mindful of the available resources as they balance the chances of one patient’s survival against those of another, when only one patient can benefit from the single available intensive care bed.
In these difficult situations, in which one doctors may well arrive at a different conclusion from another when they base their impression on gut instinct alone (or worse: the last similar patient they have seen), evidence-based guidance is crucial. Even with optimal management one in ten patients with status epilepticus will die in hospital. On the other hand, most patients with refractory status epilepticus recover and survive. Patients can be harmed by over- and undertreatment. How can we identify those who should receive maximal treatment?
My editor’s choice from the current issue of Seizure by Caroline Reindl et al. is a very welcome addition to the evidence, which can support this decision-making process (2). Reindl et al. compare the accuracy of four clinical scores designed to predict in-hospital mortality. Negative predictive value levels of 90+ per cent demonstrate that all four scores can are likely to identify probably survivors of status epilepticus with a high level of accuracy. However, given that the positive predictive values of all scores were less than 20%, this study also demonstrates that these clinical scores should not be used in isolation to make decisions about treatment escalation. Nevertheless these scores are likely to be much more accurate predictors of survival after status epilepticus than nonspecific prognostications inspired by non-neurological intensive care practice and based on the number of organs which seem compromised in a particular patient.
(1) Toerien, M., Shaw, R., Reuber, M. Initiating decision-making in neurology consultations: 'recommending' versus 'option-listing' and the implications for medical authority. Sociology of Health & Illness 2013;35,873-90.
(2) Reindl C, Knappe RU, SpruÌˆgel M, Sembill J, Mueller TM, Hamer H, Huttner H, Madzar D. Comparison of scoring tools for the prediction of in-hospital mortality in status epilepticus. Seizure 2018, please add bibliographic details.