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Multicenter Study
. 2022 Feb 1;92(2):339-346.
doi: 10.1097/TA.0000000000003400.

The patient's voice matters: The impact of advance directives on elderly trauma patients

Janet S Lee  1 , Abid D Khan, Warren C Dorlac, Julie Dunn, Robert C McIntyre Jr, Franklin L Wright, K Barry Platnick, Valerie Brockman, Stephanie A Vega, Jessica M Cofran, Colleen Duero, Thomas J Schroeppel
Affiliations
Multicenter Study

The patient's voice matters: The impact of advance directives on elderly trauma patients

Janet S Lee et al. J Trauma Acute Care Surg. .

Abstract

Background: Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (ADs) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of preinjury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality.

Methods: A multicenter retrospective review was conducted on patients older than 65 years with traumatic injury between 2017 and 2019. Three Level I trauma centers and one Level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted.

Results: There were 6,135 patients identified; 751 (12.2%) had a preinjury AD. Patients in the AD+ group were older (86 vs. 77 years, p < 0.0001), more likely to be women (67.0% vs. 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients, and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs. 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs. 39.6%, p = 0.251). A preinjury AD was identified as an independent predictor of mortality, but not a predictor of WOC.

Conclusion: Despite a high WOC rate in patients older than 65 years, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care.

Level of evidence: Prognostic and epidemiological, level IV.

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