The ethics of blood stewardship and quantitative futility assessments to predict certain death in neurotrauma patients

Universally accepted guidelines to predict futile resuscitation in severely bleeding trauma patients with traumatic brain injury do not exist. These patients may consume vast volumes of blood products in futile cases, which is especially problematic during times of local and national blood scarcity. However, determining which patients have no chance of survival is complicated and often reliant on the traumatologist's individual judgment, which may be inconsistent. Traumatologists often face the ethical dilemma of balancing their obligations to provide appropriate care for patients and to conserve blood products for other patients. To assist physicians, bedside futility algorithms have been developed, some of which emphasize the negative effects of traumatic brain injury on survival. Bedside futility algorithms may be used during futility time-outs early in the treatment of severely bleeding trauma patients who are unlikely to survive, potentially preventing blood product waste by providing guidance to clinicians in the early determination of futility and the withdrawal of life-sustaining treatment. These algorithms are steps toward the development of ethically grounded, data-driven clinical guidelines regarding the use of blood products in severely bleeding trauma patients. We compare historical and nascently proposed futility algorithms in the context of the ethical challenges of declaring futility in the severely injured population.