New somatosensory evoked potentials and prognosis after cardiac arrest
Research type
Research Study
Full title
P25/30 somatosensory evoked potentials are associated with neurological prognosis of comatose survivors after out of hospital cardiac arrest
IRAS ID
251827
Contact name
Nikitas / NN Nikitas
Contact email
Sponsor organisation
University Hospitals Plymouth NHS Trust
Duration of Study in the UK
2 years, 11 months, 30 days
Research summary
Summary of Research
Cardiac arrest is a condition when the heart stops working for a period of time as a result of multiple possible events [e.g. acute heart attack, very fast or very slow heart rate, lack of oxygen, effect of drugs etc.].
The heart starts functioning again after successful cardiopulmonary resuscitation consisting of chest compressions, electrical shocks, breathing support and administration of potent supportive medications.
Despite the successful resuscitation, this transient stop of the heart function causes all organs of the body [brain, lungs, kidneys, liver and muscles] to starve for blood and oxygen, for the period of time that the heart was not working [anoxia time].
This may result to severe failure of all body organs. The degree of this failure is determined by the period of time that the heart stopped pumping, and individual factors of each patient.
Brain is one of the most sensitive organs to any decrease of the blood or oxygen supply and it can be severely damaged in cases of cardiac arrest. Therefore, despite the successful resuscitation, brain dysfunction is a common complication after an episode of cardiac arrest. This dysfunction may vary, from transient impairment of behaviour and memory to severe disability or even coma and death due to irreversible brain damage.
One of the main aims of the ICU care after an episode of cardiac arrest is to predict the degree of brain damage and potential recovery. For this purpose many tests are used in order to predict the outcome in brain function as early as possible after a cardiac arrest. In this way it is tried to identify the patients that most likely would have a good recovery and those that their recovery would be expected to be poor.
The Somatosensory Evoked Potentials test [SSEP] is a recording of the electrical signals in the cortex [the outer layer] of the brain which is done by positioning small dots on the outer surface of the head. This test confirms the presence or the absence of specific electrical signals in the brain after a brief stimulation of one of the areas in our hands or wrists in both sides of the body.
One of the signals that has been identified and used for many years is called N20. N20 has been successfully used for many years in the prediction of the neurological recovery of patients after cardiac arrest.
During this test, the absence of the N20 electrical signal has been consistently associated with poor neurological recovery.
The presence of N20 electrical signal, which is the result of the test in the majority of cases, is not strongly associated with either poor or good neurological recovery. In this case, which unfortunately is the majority of cases, the result of the test is not very helpful for the prediction of the outcome.
Therefore, there is a need to discover more electrical signals in the brain that potentially could be used more reliably in the prediction of outcome of the patients after cardiac arrest.
The main aim of our study is the discovery of other electrical signals, similar but distinct to N20, that could be used for this purpose and to assess their reliability in predicting the outcome of the patients after cardiac arrest.
During the usual SSEP test, it was noticed that in the same recording sheet, other electrical signals [apart from N20] are recorded. These electrical signals are close to N20 but distinct from it. Their role in predicting the outcome of the brain function is not clear.
The presence or absence of those additional signals that are recorded during the usual SSEP test will be assessed in our study. Those electrical signals would be analysed by us in order to assess if they are more strongly and consistently associated with the prediction of the outcome of the brain function.
The name of these signals is P25/P30.Summary of Results
What was the purpose of the study?
For patients who have had a cardiac arrest [where the heart stops pumping blood], and are then resuscitated, whether their brain function [this is called neurological outcome] will recover, and how well their brain function will recover are often very hard to predict.
The neurological outcome of the survivors of out of hospital cardiac arrest can vary from complete brain function recovery to mild-moderate-severe disability and to brain death..
Several tests can be done after admission of the survivors of out of hospital cardiac arrest in the intensive care unit that can help predict their neurological outcome. However, each single test lacks the accuracy to be able to definitely predict what the neurological outcome will be, particularly if that outcome is favourable. Hence, the current hospital practice is to combine a number of these tests to give an overall prediction of the degree of recovery.
One such test is the recording of electrical signals in the brain after using an electrical stimulus at the wrist. This stimulus produces a signal in the form of a wave which is read on a computer by an interpreter. An example of such a reading is shown in figure 1. These are known as somatosensory evoked potentials. There are different electrical signals which can be recorded including N20 (the name given to a particular wave) which is the current standard, and for this study the P25/30 waveform [a name given to another waveform that can also be seen].The objectives of this study were the following:
1. To determine whether this additional electrical signal (P25/30) could improve the chances of predicting the neurological outcome in the survivors of out of hospital cardiac arrest.
2. To test whether P25/30 could be better in predicting the outcome of the patients after cardiac arrest compared to the N20.Why was this important?
The ability to provide more accurate information to the relatives of those patients who are post cardiac arrest in intensive care has been a long-desired ambition. This allows both clinicians and families to be better informed about the likely neurological outcome of the patient, and therefore can help decision making with respect to the continuation and length of active treatment and support in the intensive care unit and in the hospital.
The main drawback of the current N20 somatosensory evoked potential in predicting the neurological outcome is that N20 is very reliable for predicting an unfavourable neurological outcome, but less so for a favourable neurological outcome.
For example, the absence of an N20 waveform in both sides of the brain is almost 100% predictive of an unfavourable outcome, and this is widely accepted. However, the presence of the N20 in either or both sides of the brain, whilst sometimes associated with a favourable outcome, can still be seen in a high percentage of patients with unfavourable outcome.
This poses a significant challenge when trying to interpret the meaning of the presence of the somatosensory evoked potentials.
Additionally, the interpretation of the waveforms produced during somatosensory evoked potentials recording can be different depending on who the interpreter is. This is known as inter-interpreter variation.
The problem exists whereby an interpreter may attribute what is known as noise [background electrical interference] as a present waveform. Whilst patients with a truly present waveform are always interpreted as having a present waveform [this explains why when an N20 waveform is said to be absent, it’s always associated with a poor outcome], there can be many instances whereby a waveform is thought to be present but is in fact noise.
This explains why sometimes, the presence of a somatosensory evoked potential is often still associated with an unfavourable outcome. Being able to reduce both inter-interpreter variation and reduce the incorrect attribution of noise as a somatosensory evoked potential would represent significant progress in the analysis of somatosensory evoked potentials.How was the study carried out?
The participants of this study were adults who had suffered an out of hospital cardiac arrest from a medical cause, resuscitated and admitted to intensive care unit of the Derriford Hospital in Plymouth UK in a comatose state.
All patients were cared for in Derriford intensive care unit, using the same protocol of care, including maintenance of normal temperature, respiratory and heart support, and sedation.
Between 24 and 36 hours after admission to the intensive care unit, the somatosensory evoked potentials were recorded and the N20 waveform results were disclosed to the clinicians as per standard practice.
Each of the recordings were anonymised and made available to two neurophysiologists [interpreters] who were not aware of the clinical details of the participants including their neurological outcome.
The neurophysiologists then analysed the somatosensory evoked potential waveforms including the P25/30, the N20 and the combination/ratio of P25/30 and the N20 which was the “Peak-To-Trough [PTT] amplitude” [from the highest point of the waveform of N20 to the lowest point of the waveform of the P25/30]. This was possible as P25/30 follows immediately after the N20 so they could be considered together as a whole complex somatosensory evoked potential for interpretation.
The interpreters were using a cut off size [amplitude] to decide about the presence or absence of the somatosensory evoked potential. For example, if the cut-off was 0.5 microvolts, the waveform had to be equal or greater than 0.5 microvolts for it to be taken as present. The principle behind the use of a cut-off point to define presence of the somatosensory evoked potential was to reduce the possible impact of noise on the interpretation, a problem associated with the currently used interpretation of somatosensory evoked potential. The cut off points used for the somatosensory evoked potentials interpretation in this study were 0.5microvolts and 0.2 microvolts.
A member of the study team was responsible for assessing the neurological outcome [favourable or unfavourable] of the participants at hospital discharge or at 28 days post cardiac arrest [which ever came first]. The neurological outcome was assessed, and outcomes were categorised as being favourable or unfavourable based on the score of the Cerebral Performance Category [a scoring system used for assessment of neurological outcomes in patient who suffer from brain injury after cardiac arrest].
Favourable neurological outcome meant that the participant had a full recovery of their brain function or mild to moderate disability but could be independent for the activities of their daily living.
Unfavourable neurological outcome meant that the participant either had severe disability and they were dependent on others for the activities of their daily living, or they died as the direct result of the brain damage.
With the data collected, it was then possible to perform a statistical analysis to determine the relationship between the P25/30 somatosensory evoked potential and the neurological outcome and to compare this with the currently used N20. Specifically, the presence/absence of the P25/30, the cut-off size [amplitude] at which they are said to be present, and the “Peak-To-Trough amplitude” [which combined both N20 and P25/30 in one] were all interpreted.What were the results of the study?
The required sample size was initially planned to be 115 participants.
No power was assumed in the calculation of the sample size as there was no testing of hypothesis.
The final number of enrolled participants was 93 instead of 115.
The reason for this lower than predicted number of participants was mainly the COVID pandemic which emerged when the study was in its 15th month of recruitment and lasted until the end of the study period [36 months].
During the COVID pandemic the number of admissions of comatose survivors of out of hospital cardiac arredt was reduced significantly due to the lockdowns [March 2020-August 2020 and from November 2020-April 2021].
Even though the study team maximised their efficacy by practically not missing any eligible patient on screening process and even though all eligible participants approached for consent provided consent, the maximum number of participants enrolled could not be higher than 93 at the completion of the study period.
Given that the study was not interventional and was producing singe-centre data which could be used as a basis for a larger multi-centre study, all members of the study team, after discussion with the sponsor, unanimously made the decision not to apply for extension of the study period beyond the 36 months but to complete the study at its expected time point [28th September 2021].
During the study period [October 2018 to September 2021], 129 patients were admitted to Derriford intensive care unit after out of hospital cardiac arrest. The patients were identified on admission as potentially eligible for enrolment to the study and all 129 were successfully screened.
No potentially eligible patient was missed from the screening.
93 out of the 129 admitted survivors of out of hospital cardiac arrest enrolled to the study after obtaining informed consent from their consultees [NOK had been previously assigned by the participant and their details had been included in and confirmed by the participant’s medical records] and/or the participants where the latter was applicable.
36 of the 129 admitted patients were not enrolled to the study due to either meeting exclusion criteria [24], or duty intensive care unit consultant’s decision [10] or technical issues with recording [2].
93 participants included initially to the analysis. For 4 out of the 93 participants the accurate and reliable assessment of the CPC was not possible. Therefore, those 4 participants were excluded from the analysis as per study protocol. Hence, finally, 89 participants included to the analysis None of the participants or consultees [where each one was applicable] has requested to withdraw from the study after their initial enrolment. All participants have agreed to continue to the study after their consultees had initially provided consent for their participation in the study.Clinical results
For the 89 participants finally included in final analysis:
43.8% [39] of the participants had a favourable neurological outcome and 56.2% [50] had an unfavourable neurological outcome at hospital discharge.
The proportion of those died [mortality] at hospital discharge or at 28 days [whichever happened first] was 98% [49] in the participants with an unfavourable neurological outcome compared to 2.6% [1] in those with a favourable neurological outcome.
The death occurred within a period of 7.63 days after resuscitation in the participants with unfavourable neurological outcome.
The mean age of the participants was 58.4 years for those with favourable outcomes and 58.9 years for those with an unfavourable outcome.
74.2% [66] of participants were male and 25.8% [23] were female with no significant difference in outcome.
43.9% [29] of male and 43.5% [10] of female participants had a favourable outcome whereas 56.1% [37] of male participants and 56.5% [13] of the female participants had an unfavourable outcome.
The mean time of P25/30 recording after resuscitation was 25.2 hours in the participants with favourable outcome and 26.3 hours in the participants with unfavourable neurological outcome.
The consistency in the timing of recording ensured that the effect of time variations on the result which can potentially happen overtime minimised in this study, by focusing entirely on the early stages after resuscitation.
The mean temperature during recording was the same in the participants of both groups of neurological outcomes at 36.1oC with minimal possible variation. This was the result of the consistency in the temperature management of the participants in our study.P25/30 and prediction of the neurological outcome
The results are presented for the 89 participants who were included in the final study analysis.
The results of the analysis of the association of the P25/30 SSEP with the neurological outcome of the participants, (the primary endpoint of this study), were the following:
1. P25/30 to predict the neurological outcome. Presence or absence of P25/30 were based on the size of P25/30 against the cut-off of 0.5microvolts.
According to the results of the analysis for the P25/30:
The probability of a participant to have truly favourable neurological outcome when the P25/30 was present was 81.82% whereas the probability of a participant to have truly unfavourable neurological outcome when the P25/30 was absent was 84%.The P25/30 results were compared with the results of the N20 in the same 89 participants using the same 0.5 microvolts cut-off.
According to the results of the analysis for the N20:
The probability of a participant to have truly favourable neurological outcome when the N20 was present was 89.74% whereas the probability of a participant to have truly unfavourable neurological outcome when the N20 was absent was 92%.In conclusion these results showed that:
When the cut-off of 0.5 microvolts is used, the presence of P25/30 can predict the favourable neurological outcome accurately in 81.82% of participants but it is not as good as the N20, the accuracy of which is 89.74%.
Additionally, when using this cut-off of 0.5microvolts the ability of both the P25/30 and the N20 to predict accurately the unfavourable neurological outcome is reduced from 100% to 84% and 92% respectively.
This means that a few participants [specifically 3 participants] with absent P25/30 would still have a favourable outcome, a result that could have serious consequences in the clinical practice as this may have led to early Withdrawal of Life Sustaining Treatment of patients who otherwise could have had a favourable outcome.
In this context, the presence of the P25/30 using a cut-off of 0.5microvolts could not be acceptable for use in the clinical practice based on the above chance of misinterpreting a favourable outcome as unfavourable.2. P25/30 to predict the neurological outcome. Presence or absence of the P25/30 were based on the size of P25/30 against the cut-off of 0.2microvolts.
The presence and absence of the P25/30 was also interpreted based on the size of P25/30 against the cut-off of 0.2 microvolts. The reason this cut off was selected additionally to the cut off of 0.5microvolts was because in the vast majority of the somatosensory evoked potentials recordings the size of the background noise is not higher than 0.2 microvolts.
According to the results of the analysis for the P25/30:
The probability of a participant to have truly favourable neurological outcome when the P25/30 was present was 73.58% whereas the probability of a participant to have truly unfavourable neurological outcome when the P25/30 was absent was 100%.The P25/30 results were compared with the results of the N20 in the same 89 participants using the same 0.2 microvolts cut-off.
According to the results of the analysis for the N20:
The probability of a participant to have truly favourable neurological outcome when the N20 was present was 67.24% whereas the probability of a participant to have truly unfavourable neurological outcome when the N20 was absent was 100%.In conclusion these results showed that:
All participants with absent P25/30 had unfavourable outcomes.
The presence of P25/30 was able to predict accurately the favourable outcome in a higher number of participants who recovered compared to the N20 at the same cut-off.
When the cut-off of 0.2microvolts was used for the definition of the presence of the P25/30, the chances to predict the favourable outcome to the participants who recovered was 73.58%, higher than that of the N20 (67.24%).
At the same time, the chances of P25/30 to predict the unfavourable neurological outcome to those participants who did not recover was 100%, meaning as good as that of the N20.
Compared to the N20, the presence of P25/30 SSEP reduced the chances of falsely predicting the outcome from 38% to 30%.3. Combination of P25/30 and N20 in one SSEP: “Peak To Trough [PTT] amplitude” of the 20-30msec complex. Using a cut-off of 0.6 microvolts to test the ability of this combination of SSEP to predict the neurological outcome.
When the P25/30 and N20 SSEP were used in combination as the Peak To Trough [PTT] amplitude then the need to define the presence and absence of the P25/30 was no longer applicable.
Instead, the different sizes of the PTT were tested for their ability to predict the neurological outcome.
The statistical analysis was done to find a cut-off size for which all the participants who had lower from this size PTT would have poor outcome. A large range of cut-off sizes was tested and finally the 0.6 microvolts cut-off size was chosen.According to the results of the analysis for the PTT:
The probability of a participant to have truly favourable neurological outcome when the PTT was equal or higher than 0.6 microvolts was 79.59% whereas the probability of a participant to have truly unfavourable neurological outcome when the P25/30 was absent was 100%.The PTT results were compared with the results of the P25/30 alone in the same 89 participants using the 0.2 microvolts cut – off to define the presence and absence of the P25/30.
According to the results of the analysis for the P25/30 alone:
The probability of a participant to have truly favourable neurological outcome when the N20 was present was 73.58% whereas the probability of a participant to have truly unfavourable neurological outcome when the P25/30 was absent was 100%.The PTT results were compared with the results of the N20 in the same 89 participants using the 0.2 microvolts cut-off to define the presence or absence of N20.
According to the results of the analysis for the N20:
The probability of a participant to have truly favourable neurological outcome when the N20 was present was 67.27% whereas the probability of a participant to have truly unfavourable neurological outcome when the N20 was absent was 100%.The results of the PTT were compared with those of P25/30 and N20 using the threshold of the 0.5 microvolts to define the presence and absence of P25/30 and N20. Still on this analysis PTT was superior prognostically to P25/30 alone both for the prediction of the favourable and unfavourable outcomes and compared to N20 it was superior to N20 in predicting the unfavourable outcome but inferior to N20 in predicting the favourable outcome. However, given the lower than 100% predictive strength of P25/30 and N20 to predict the unfavourable outcome when the 0.5 microvolts threshold was used for the definition of their presence and absence we do not believe that this comparison could be realistic and thus acceptable in clinical practice.
In conclusion these results showed that:
The PTT amplitude, using a cut-off size of 0.6microvolts, achieved to predict the favourable neurological outcome in the highest number of participants [79.59%] who recovered, while at the same time was able to predict the unfavourable outcome in all [100%] participants that did not recover. The use of PTT also reduced the chance of falsely predict the outcome to 24%.
The ability of PTT amplitude to predict the outcome was better than that of P25/30 or N20 when used alone.
This means that when we combine the P25/30 and N20 in the interpretation of the waveforms as the Peak to Trough ratio between them [The PTT] and when the size of the PTT size is above 0.6 microvolts we can potentially predict more reliably the favourable neurological outcome reducing the chance of error to the lowest possible percentage.
Using the PTT to predict the outcome ended up with a 100% agreement between the two interpreters. This finding can be very important for the daily practice in the hospital and could lead to an easier and more standard interpretation of the SSEP between the different hospitals and between different patients.
4. Somatosensory evoked potential interpretation without measuring the size of the SSEP but based only on the opinion of the interpreter who looks at the waveform. This is the currently available hospital N20 test [both nationally and internationally] that is used at bedside to predict the outcome.
In our study we compared our results of the P25/30 and the Peak-To-Trough amplitude that presented above with the currently available N20 hospital test. During the daily hospital practice when the N20 somatosensory evoked potential is used at bedside to predict the outcome its presence or absence is based on the judgement of the interpreter and not on the size of N20 against any cut-off point.
The results of this comparative analysis showed that the way we test the N20 somatosensory evoked potential in bedside hospital practice had lower ability [62.9%], compared to P25/30 [73.58%] and PTT amplitude [79.59%], to predict the favourable outcome in those participants who recovered, whereas it was equally able to predict the unfavourable outcome in all participants who did not recover [100% success].
Therefore, the use of P25/30 or PTT can achieve higher chances of reliably predicting the favourable neurological outcome among the participants compared to the currently available hospital test.Conclusively presenting the key results/messages of the study in lay terms, the study showed that:
-The P25 / 30 SSEP when present, achieved higher chances to predict the favourable neurological outcome in the participants who recovered compared to N20. That means that when the P25/30 was present it was strongly related to the favourable neurological outcome.-The higher chance the P25 / 30 to predict the short-term neurological outcome of the participants compared to N20 was achieved when the P25/30’s presence was based on its size against a cut-off point of 0.2microvolts from a defined in a standard way baseline.
-The P25/30 SSEP showed a lower chance to falsely predict the short-term outcome of the participants compared to N20.
-The P25/30 SSEP when it was absent it was able to predict the unfavourable outcome in the participants who did not recover. This performance was equal to the one of the N20.
-When the cut-off point used to define P25/30 presence was 0.5microvolts then the P25/30 showed lower chance to predict the outcome compared to N20.
-However due to decreased [below 100%] efficacy of P25/30 and N20 to predict the unfavourable neurological outcome when absent the application of 0.5 microvolts as a threshold to define their presence cannot be accepted as applicable in clinical practice.
-The combination of the P25/30 and the N20 as the Peak to Trough [PTT] amplitude showed the highest possible chance to predict the favourable neurological outcome in the participants [when used the cut-off size of 0.6microvolts]. At the same time the PTT maintained the same predicting efficacy with that of the P25/30 and N20 for the unfavourable neurological outcome.
-The Peak to Trough of the 20-30msec complex SSEP [PTT] demonstrated the lowest possible chance to falsely predict the favourable neurological outcome compared to P25/30 and N20 when used alone.
-Both the P25/30 alone and when interpreted in combination with N20 as PTT showed higher ability to predict accurately the neurological outcome compared to the currently available hospital bedside N20 test.
-The PTT showed a. easier and more consistent and standard definition, b. no need for determining a baseline to estimate its size, c. no need to define its presence and absence in order to use for the prediction of the outcome, d. no effect of the background noise during the recording.
-The recording and interpretation of the Somatosensory evoked potentials within the first 24-36 hours after the resuscitation can potentially predict efficiently the short-term neurological outcome in the survivors of the Out of Hospital Cardiac Arrest who are in a coma after the resuscitation.
The limitations of the study can be summarised as follows:
-This was a single-centre observational study, and the number of study participants was low. Therefore, the study was not powered to produce definitive conclusions regarding association between P25/30 with neurological outcome.
-The period of follow up was short [up to hospital discharge]. Therefore, the assessed neurological outcome was the short-term neurological outcome of the participants and not the long-term one.
-The Cerebral Performance Category scale which was used for the assessment of the short-term neurological outcome of the participants was not an ideal, but it was chosen as it is the most used score for the assessment of the neurological outcome in survivors of the out of hospital cardiac arrest.
-The COVID -19 pandemic which emerged in the middle of the study period, resulted in significant reduction in admissions of survivors of out of hospital cardiac arrest to the Derriford intensive care unit and adversely affected study recruitment rates and final total number of participants. Also it modified the demographic characteristics of the study cohort with increasing numbers of younger and free of comorbidities participants.
-The effect of the Withdrawal of Life Sustaining Treatment on the definition of the neurological outcome and the statistical associations between somatosensory evoked potentials and prediction of this outcome remains unclear and difficult/challenging to estimate in a statistical way.The strengths of the study can be summarised as follows:
-The study was a prospective observational study with standardisation and control of the conditions of the study conduction.
-The methods of the somatosensory evoked potentials recording and interpretation were standardised and applied in the same way in all participants.
-There was consistency in timing of somatosensory evoked potentials recording post resuscitation. None of the participants had a recording longer than 36 h or shorter than 24 h post ROSC.
-There was consistency in participants’ temperature level during recording in both the favourable and the unfavourable outcome groups.
-There was a standardisation in the analysis of somatosensory evoked potentials recordings, in the definition of baseline, in the definition of thresholds to define the P25/30 presence and absence -Interpreters were blinded to each other about the results of their interpretation.
-The original Somatosensory evoked potential recording and not the grand average paper bedside recording was used for SSEP interpretation, increasing in this way the accuracy and reliability of the interpretation [e.g., amplitude measurement, definition of baseline].
-This was a real-life study which was conducted in a British ICU without any effect on medical decision making and the treatment of the participants as the clinicians were blinded to the results.What do the results of the study mean?
In conclusion, it could be suggested that the results of our study provided evidence that the addition of the P25/30 in the analysis of the recorded somatosensory evoked potentials can potentially improve the prediction of the short-term neurological outcome after out of hospital cardiac arrest.
Given its higher ability to predict accurately the favourable neurological outcome and the achieved 100% agreement between the interpreters, the combination of the P25/30 and the N20 as the Peak to Trough [PTT] amplitude can potentially be used as a novel somatosensory evoked potential improving the accuracy in prediction of the neurological outcome after cardiac arrest.Using measurement of the size [amplitude] of the P25/30 to decide about its absence or presence can be associated with higher chances of predicting accurately the neurological outcome after cardiac arrest. This potentially can standardise the way somatosensory evoked potentials recording is interpreted in daily clinical practice and subsequently improve the predictive value of N20 and P25/30 and make results from different centres generalisable and reproducible. From methods perspective, our study suggested a way that potentially this could be achieved.
The methods and the results of our study would be potentially useful to be further tested in a large multi-centre prospective observational trial in an effort to improve the prediction of the brain recovery outcome in the survivors of cardiac arrest.
The improvement in prediction of the outcome potentially could lead to improvement of the decision making by the doctors, could make us able to answer earlier the questions of the families with regards to the predicted outcomes of their loved ones and could help optimising the costs of the NHS by tailoring the treatment and support to the patient’s accurately predicted outcome.
REC name
North West - Haydock Research Ethics Committee
REC reference
18/NW/0623
Date of REC Opinion
13 Sep 2018
REC opinion
Favourable Opinion