Withdrawal of Life-supporting Treatment in Severe Traumatic Brain Injury

Abstract

Importance: There are limited data on which factors affect the critical and complex decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury (sTBI).

Objective: To determine demographic and clinical factors associated with the decision to withdraw LST in patients with sTBI.

Design, setting, and participants: This retrospective analysis of inpatient data from more than 825 trauma centers across the US in the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2015 included adult patients with sTBI and documentation of a decision regarding withdrawal of LST (WLST). Data analysis was conducted in September 2019.

Main outcomes and measures: Factors associated with WLST in sTBI.

Results: A total of 37931 patients (9817 women [25.9%]) were included in the multivariable analysis; 7864 (20.7%) had WLST. Black patients (4806 [13.2%]; odds ratio [OR], 0.66; 95% CI, 0.59-0.72; P < .001) and patients of other race (4798 [13.2%]; OR, 0.83; 95% CI, 0.76-0.91; P < .001) were less likely than white patients (26 864 [73.7%]) to have WLST. Patients from hospitals in the Midwest (OR, 1.12; 95% CI, 1.04-1.20; P = .002) or Northeast (OR, 1.23; 95% CI, 1.13-1.34; P < .001) were more likely to have WLST than patients from hospitals in the South. Patients with Medicare (OR, 1.55; 95% CI, 1.43-1.69; P < .001) and self-pay patients (OR, 1.36; 95% CI, 1.25-1.47; P < .001) were more likely to have WLST than patients with private insurance. Older patients and those with lower Glasgow Coma Scale scores, higher Injury Severity Scores, or craniotomy were generally more likely to have WLST. Withdrawal of LST was more likely for patients with functionally dependent health status (OR, 1.30; 95% CI, 1.08-1.58; P = .01), hematoma (OR, 1.19; 95% CI, 1.12-1.27; P < .001), dementia (OR, 1.29; 95% CI, 1.08-1.53; P = .004), and disseminated cancer (OR, 2.82; 95% CI, 2.07-3.82; P < .001) than for patients without these conditions.

Conclusions and relevance: Withdrawal of LST is common in sTBI and socioeconomic factors are associated with the decision to withdraw LST. These results highlight the many factors that contribute to decision-making in sTBI and demonstrate that in a complex and variable disease process, variation based on race, payment, and region presents as a potential challenge.

Figure 1.. Illustration of Study Design and Number of Individuals Meeting Criteria for Inclusion

Severe traumatic brain injury (TBI) was defined as an Abbreviated Injury Scale (AIS) score of 2 to 6 and a Glasgow Coma Scale (GCS) score of 3 to 8. The demographic predictors investigated included age group, sex, race, payment status, geographic region, teaching status of the hospital, number of neurosurgeons, and interhospital transfers. The clinical predictors included GCS group, Injury Severity Score (ISS) group, functionally dependent health status, penetrating vs blunt injury, presence or absence of hematoma, craniotomy vs no craniotomy, dementia, cerebrovascular accident (CVA) with residual neurological deficiency, chronic renal failure, and disseminated cancer. The interaction terms included GCS group and ISS group, GCS and age group, and GCS score and craniotomy. WLST indicates withdrawal of life-supporting treatment.

Figure 2.. Odds Ratio Estimates for Withdrawal of Life-supporting Treatment (WLST)

Odds ratio estimates for the unknown levels vs the reference levels are omitted. Error bars indicate 95% CIs. CVA indicates cerebrovascular accident.