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Multicenter Study
. 2011 Oct 4;183(14):1581-8.
doi: 10.1503/cmaj.101786. Epub 2011 Aug 29.

Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study

Alexis F Turgeon  1 , François Lauzier, Jean-François Simard, Damon C Scales, Karen E A Burns, Lynne Moore, David A Zygun, Francis Bernard, Maureen O Meade, Tran Cong Dung, Mohana Ratnapalan, Stephanie Todd, John Harlock, Dean A Fergusson; Canadian Critical Care Trials Group
Affiliations
Multicenter Study

Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study

Alexis F Turgeon et al. CMAJ. .

Abstract

Background: Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine.

Methods: To evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale).

Results: We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%-35.2%) and ranged from 10.8% to 44.2% across centres (χ(2) test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%-75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ(2) test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care.

Interpretation: We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.

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Figures

Figure 1:
Figure 1:
Adjusted odds ratios for hospital mortality by centre. Odds ratios were adjusted for sex, age, pupillary reactivity and patients’ scores on the Glasgow coma scale. An odds ratio greater than 1.00 is associated with greater odds of death; an odds ratio of less than 1.00 is associated with lower odds of death. Error bars indicate 95% confidence intervals.
Figure 2:
Figure 2:
Adjusted odds ratios for hospital mortality following withdrawal of life-sustaining therapy by centre. Odds ratios were adjusted for sex, age, pupillary reactivity and patients’ scores on the Glasgow coma scale. An odds ratio greater than 1.00 is associated with greater odds of death; an odds ratio of less than 1.00 is associated with lower odds of death. Error bars indicate 95% confidence intervals.
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