Procedures, Ethics, Communication, Palliative Care, and Systems-Based Practice
Procedures
External ventricular drain placement risks hemorrhage, malposition, and infection; use antibiotic-impregnated catheters, avoid prolonged drainage, and never flush the drain. Lumbar puncture is deferred for focal deficits, seizures, papilledema, coagulopathy, or cardiopulmonary instability, and anticoagulation must be held appropriately. Timing of tracheostomy has not consistently improved outcomes when studied rigorously, so decide on trajectory rather than on a fixed day.
Communication and ethics
Conduct structured family meetings using plain language, summarize what the team understands, elicit the patient's values, and confirm what the family heard. Surrogate decision makers should apply substituted judgment, not their own preferences. Withdrawing and withholding life-sustaining treatment are ethically equivalent; neither is euthanasia or assisted suicide. Involve interpreters and palliative care early; palliative consultation improves symptom control and goal concordance.
Organ donation discussions belong to organ procurement organizations, not the treating team, and must be separated from the decision to withdraw.
Trap: treating family disagreement as a legal problem before exploring misunderstanding or unresolved grief, or documenting a code status without a goals-of-care conversation.
Rule of thumb: ask what the patient would have wanted, not what the family wants, and confirm understanding by asking the family to restate the plan in their own words.