Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis

Abstract

Among patients with severe traumatic brain injury (TBI), there is high prognostic uncertainty but growing evidence that recovery of independence is possible. Nevertheless, families are often asked to make decisions about withdrawal of life-sustaining treatment (WLST) within days of injury. The range of potential outcomes for patients who died after WLST (WLST+) is unknown, posing a challenge for prognostic modeling and clinical counseling. We investigated the potential for survival and recovery of independence after acute TBI in patients who died after WLST. We used Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) data and propensity score matching to pair participants with WLST+ to those with a similar probability of WLST (based on demographic and clinical characteristics), but for whom life-sustaining treatment was not withdrawn (WLST-). To optimize matching, we divided the WLST- cohort into tiers (Tier 1 = 0-11%, Tier 2 = 11-27%, Tier 3 = 27-70% WLST propensity). We estimated the level of recovery that could be expected in WLST+ participants by evaluating 3-, 6-, and 12-month Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale outcomes in matched WLST- participants. Of 90 WLST+ participants (80% male, mean [standard deviation; SD] age = 59.2 [17.9] years, median [IQR] days to WLST = 5.4 [2.2, 11.7]), 80 could be matched to WLST- participants. Of 56 WLST- participants who were followed at 6 months, 31 (55%) died. Among survivors in the overall sample and survivors in Tiers 1 and 2, more than 30% recovered at least partial independence (GOSE ≥4). In Tier 3, recovery to GOSE ≥4 occurred at 12 months, but not 6 months, post-injury. These results suggest a substantial proportion of patients with TBI and WLST may have survived and achieved at least partial independence. However, death or severe disability is a common outcome when the probability of WLST is high. While further validation is needed, our findings support a more cautious clinical approach to WLST and more complete reporting on WLST in TBI studies.

Keywords: coma; traumatic brain injury; withdrawal of life-sustaining treatment.

FIG. 1.

Withdrawal of life-sustaining treatment (WLST) propensity scores. The cohort with WLST (WLST+, red) had on average a substantially greater propensity (i.e., predicted probability) for WLST than those without WLST (WLST−, blue). However, the propensity for WLST in many WLST− participants overlapped with the WLST+ cohort. Box and whisker plots indicate median, interquartile range (box), 1.5 × interquartile range (whiskers) and outliers (points outside the whiskers in the WLST− group).

FIG. 2.

Days from injury to withdrawal of life-sustaining treatment (WLST). WLST occurred within 3 days of injury for more than 30% of the WLST+ cohort. All participants in Tier 4, which represents the oldest and most severely injured patients, died within 7 days of injury.

FIG. 3.

Outcome of participants without withdrawal of life-sustaining treatment (WLST−) who were matched to participants who died after withdrawal of life-sustaining treatment (WLST+). Death represents the most common outcome at 3 months, 6 months, and 12 months. However, among survivors, more than 50% of those in Tier 1 and 50% of those in Tier 2 regain at least partial independence (often categorized as a “favorable outcome”) by 6 months post-injury. Although the likelihood of recovery for those in Tier 3 was low, even in this older and more severely injured cohort two participants achieved a Glasgow Outcome Scale Extended (GOSE) category of upper moderate disability (independent but with some limitations in work, leisure, and/or personal relationships) by 12 months post-traumatic brain injury.