[Deciding on surgery for acute subdural haematoma; does a neurosurgeon rather fill nursing homes or cemeteries?]

Acute subdural haematoma is a life-threatening condition that can sometimes be mitigated by decompressive craniotomy. However, it can also increase misery when patients survive but are left with severe disabilities. A recent publication shows that neurosurgeons in Belgium and the Netherlands vary considerably in their opinion regarding if, and when, to perform this surgery. This may be due to the fact that this type of intervention asks the question whether the life saved is more favourable than the death averted. This requires a value judgement that has to be informed by the flawed and incomplete medical literature and by the perhaps even more flawed and incomplete (relayed) accounts of the wishes and attitudes of the unconscious patient. However, in the end, the surgeon also evaluates his own convictions in the whole issue and this will inevitably introduce subjectivity and practice variation. A structured moral debate may help to improve the extremely difficult decision-making process around the management of acute subdural haematoma.