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  • The Ordeal of RemindingTraumatic Brain Injury and the Goals Of Care
  • Bruce Jennings (bio)
Abstract

The appropriate goal of care for a person with a traumatic brain injury is rehabilitation in the broad, etymological sense of the word. The task is to bring the person back to the conditions of the living of a life. This requires the rehabilitation of the mind—the reconstruction of a subject.

Traumatic brain injury is a thief. Each year two million Americans suffer some form of TBI, and 373,000 of these people are injured seriously enough to require hospitalization. Of these, some 90,000 require extended periods of rehabilitation. They survive, they continue their lives, they carry on. Others are not so fortunate. Sixty thousand people die each year from TBI, and another 2,000 are left in a permanent unconscious state.1 TBI is a significant, if not widely recognized, public health problem.

TBI is not a random thief. Most frequently, it visits the young. More than half of those with TBI are men between the ages of fifteen and twenty-four. It is a leading cause of death among children and young adults. TBI strikes the young because it is most often a result of the physical activities and lifestyles of the young, and perhaps because neither caution nor precaution are among the natural virtues of youth. Automobile accidents account for the vast majority of TBIs; alcohol and drug use hover over these statistics. Families immediately become involved when TBI occurs; two-thirds of TBI victims live with spouse or other family, and for those living alone at the time of the accident or injury, some family members must be called into the situation, since immediate and emergency medical decisions have to be made. Ask any family member (or person who has undergone TBI and whose memory is not impaired), and they will be [End Page 29] able to tell you the exact date, time, and place it occurred. TBI is a fundamental turning point in lives.

Different regions of the brain seem to control different functions and capacities, both bodily and behavioral, both cognitive and affective; although the more we learn about the workings of the brain, the more complexity and redundancy we find. Thus TBI's effects often seem capricious and inexplicable. Moreover, the range of impairments associated with TBI is remarkably wide, from permanent loss of all consciousness, sensation, and awareness, to little disabilities so trivial and nonintrusive that the person herself may even forget about them most of the time, and others would never know about the injury, or notice any impairment, unless they were told.

TBI can arise from physical trauma or from a prolonged loss of oxygen to the brain, and rather different kinds of injury and impairment may result depending on the underlying cause. Swelling of the brain and intracranial pressure soon after the injury has occurred are the principal causes of death, not so much the brain damage itself. Therefore better and faster modes of emergency care following a TBI have been able to increase dramatically the number of survivors in recent years. TBI-related disability is an artifact of medicine's technological success—its "halfway" success, in Lewis Thomas's apt phrase.2

Medical decision-making in the first hours, days, and weeks after the injury is exquisitely difficult and complicated by prognostic uncertainty. It is only much later that the full extent of the person's recovery can be known, and often not even then. Recovery is also variable. Recovery and change are lifelong processes after TBI.

TBI can cause impairments that are both physiological and behavioral. On the one side, there may be an inability to use limbs, sensory deprivations, balance problems, and a new kind of physical fragility that makes one more prone to medical problems. On the other side are troubles that affect one's use of language, memory, personality, feelings, and judgments and social skills—what some refer to as the "executive functions" of the person.

William Winslade, author of the only book-length study of the ethical issues associated with the treatment of TBI, dryly observes, "Survivors of a severe traumatic brain injury typically face...

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