Upstream/Downstream

Withdrawal of life-sustaining treatment is the leading factor in deaths after brain injuries: 64 to 92 percent of neurointensive care deaths occur after treatment withdrawal, most within the first 72 hours after injury. There is risk inversion in the way the upstream and downstream ethical risks are weighed for comatose patients. The inversion occurs when more certain risks are undertaken upstream (in neurointensive care) to avoid less certain, more speculative risks downstream. These are ethical risks—the upstream risk is that withdrawing life-sustaining treatment soon after a brain injury will result in death, and a lost opportunity to survive and live a good and flourishing life. The downstream risk is that the patient will survive, but in a condition that is unacceptable to them. The upstream/downstream problem is a wicked problem, where each solution can create new problems. Whether the risks can, and should, be reinverted is the question.