A 38-year-old male was admitted due to traumatic brain injury. Upon admission, the Glasgow coma score was 3, with bilateral non-reactive mydriasis (6mm) and the absence of corneal reflexes. The brain computed tomography scan showed multiple hemorrhagic contusions, massive brain edema with compression of the peri-mesencephalic cisterns, and left subdural hematoma with mass effect. Given the Glasgow score and the absence of brainstem reflexes, Neurosurgery decided against surgical intervention. After three hours without sedation, the patient remained with bilateral non-reactive mydriasis (6mm) but had recovered the corneal reflexes and showed decerebration rigidity motor responses. Upon re-evaluation by Neurosurgery, and despite the bilateral non-reactive mydriasis and dire prognosis, surgery with evacuation of the subdural hematoma was carried out, with left DC and ICP monitoring with a Camino® catheter, in view of the age of the patient. The course proved negative, with a sustained ICP of over 40mmHg, refractory to all kinds of treatment (deep sedation, analgesia, neuromuscular block, controlled hyperventilation, hypertonic saline infusion, mannitol and DC). The computed tomography scan showed ischemic areas in the brainstem, territory of the right anterior cerebral artery and left brain hemisphere (territory of the middle and posterior cerebral arteries). After 5 days, and with the suspicion of BD, sedation was suspended. After 48h without sedation, the patient presented a Glasgow score of 3, bilateral non-reactive mydriasis and the absence of photomotor, cranial, oculocephalic and cough reflexes, maintaining only spontaneous breathing. The electroencephalogram (EEG) showed the absence of brain bioelectrical activity in the left brain hemisphere, and minimum activity with suppression phases in the right hemisphere. The neurological exploration, the computed tomography findings and the EEG tracing confirmed that the patient suffered catastrophic and irreversible brain damage, with no chance of recovery. The supervising physician made the following assessment: the natural course of these injuries is towards BD, though this is impeded by DC initially intended to help save the life of the patient, but which has failed and now artificially prolongs a terminal situation. In this case two options were considered:

• (A)

  Decompressive craniotomy no longer improves the situation and only prolongs a terminal condition. It therefore would be acceptable to cancel its effects by means of a cranioplasty with bandage. In this case, death would occur according to neurological criteria.

• (B)

  The application of LSTL through terminal extubation, likewise considering that intubation and mechanical ventilation are futile and only prolong a terminal patient condition. In this case, death would occur according to cardiorespiratory criteria.

The case was discussed in clinical session, and since patient recovery was considered impossible, all the physicians in the Department agreed to apply LSTL. Of the two abovementioned options, the supervising physician chose cranioplasty with bandage, with the criterion that this would ensure a course more consistent with the natural evolution of the initial injury. The relatives of the patient were informed in detail of the reasons for this decision and of its possible consequences. Twenty-four hours later, after obtaining consent from the family, and in the absence of prior wills, the patient donated 6 organs (seventh day of admission).

All the consulted experts in medical ethics were asked the following question:

In a patient with catastrophic and irreversible brain damage, in which LSTL is decided, is it ethically correct to perform cranioplasty with bandage in order to facilitate evolution towards BD? Should this option be preferred over other forms of LSTL, taking into account the possibility of organ donation?

The experts agreed on the following points:

• (1)

  From the scientific and ethical perspective, in the event of catastrophic neurological damage, it is advisable to adapt treatment to the expectations for recovery and the wishes of the patient, if these have been previously expressed.20 Maintaining futile treatment is regarded as poor clinical practice, since it goes against human dignity. The physician should always avoid unwarranted insistence upon treatment. Limiting life support measures that only serve to artificially prolong life without possibilities for recovery of the patient, having established consensus among the attending physicians and relatives, constitutes correct practice consistent with the recommendations referred to end of life care, Spanish legislation, and the accepted ethical standards.21 LSTL in these situations avoids undue suffering for the family and also the unnecessary consumption of healthcare resources. In the present case, cranioplasty with bandage is considered good medical practice.

• (2)

  Reverting the effect of decompressive surgery when the latter is no longer effective and indeed proves futile cannot be assumed in terms of surgical replacement of the bone flap, since this would constitute an unjustified consumption of resources. Reverting the effect of decompressive surgery through cranioplasty with bandage may be regarded as ethically similar to other forms of LSTL, since it does not violate the principles of beneficence and non-maleficence.

• (3)

  Attending the principle of autonomy, it must be determined whether the patient expressed or left instructions referred to LSTL and organ donation. If not so, then the relatives or legal representatives should make the decisions on the basis of what they know. In this respect, it is necessary to provide the family with exhaustive, detailed and transparent information on the entire process.

• (4)

  If the patient expressed a wish to donate his or her organs, or in the event of family consent through delegation, the implicated healthcare professionals must do everything possible to satisfy the expressed wish—preserving the principle of autonomy and abiding with the principles of social solidarity. In the present case it would be indicated to apply LSTL involving cranioplasty with bandage, since a fatal outcome under conditions of brain death would facilitate organ donation. In this context it must be remembered that donation under non-heart beating donor conditions (in cases of death according to cardiorespiratory criteria after terminal extubation) is exceptional, and is unable to guarantee organ harvesting for transplantation.

  From the ethical perspective, we are obliged to contemplate organ donation, since there are many patients on the transplant waiting list who could benefit as a result. Some authors22 have estimated that a multiorgan donation comprising 6 organs generates 55.8 years of life for the different recipients, and thus represents an important social benefit consistent with the principles of justice. The World Health Organization,23 the Spanish national medical organization (article 48 of the Code of Medical Ethics and Deontology24), and the ethical code of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)25 consider it an obligation of all health professionals to encourage and promote organ donation. Moreover, the family members of the patient can find certain consolation in donation, since by doing so, they are contributing to save the life or improve the quality of life of other people. It must be remembered that organ donation contributes greatly to a fairer society, with values such as solidarity, altruism, compassion, or the correction of inequalities. On the other hand, transplantation practice has been shown to be very efficient in terms of healthcare resource utilization.

• (5)

  In the ICU, the disconnection of mechanical ventilation and/or terminal extubation is a common element in LSTL. The fact that protocolized extubation is traditionally and most frequently decided does not mean that this LSTL modality should prevail over other options such as cranioplasty with bandage, particularly in those cases where there is a possibility for organ donation.

Therefore, cranioplasty with bandage can be regarded as good clinical practice, consistent with the general aims of medical practice as defined by the Hastings Center.26

In many cases, decompressive craniotomy can save the life of neurocritical patients, and our obligation as intensivists is to offer our patients all possible opportunities for recovery. Unfortunately, in cases characterized by a very poor course and devastating injuries, DC may prove futile and can moreover impede natural evolution of the patient condition towards brain death.

After pondering this clinical case, it can be concluded that cranioplasty with bandage is an ethically acceptable form of LSTL. Its application is of undeniable social value, since it facilitates organ donation. In these cases, it is necessary to know the existence of prior instructions and to adequately inform the family of the patient with a view to obtaining consent.

Social and professional practices change slowly, and good reasons, profound reflection and broad knowledge are needed to facilitate change. We are therefore obliged to continue our research and specific training of health professionals in relation to the new forms of LSTL and organ donation.

The authors declare that they have no conflicts of interest.