Racial and Ethnic Differences in Withdrawal of Life-Sustaining Treatment and Hospice Referral in Severe Traumatic Brain Injury

doi:10.1007/s40615-025-02476-9

. 2025 May 16.

doi: 10.1007/s40615-025-02476-9. Online ahead of print.

Racial and Ethnic Differences in Withdrawal of Life-Sustaining Treatment and Hospice Referral in Severe Traumatic Brain Injury

Erin Hennessey¹, Tamriage Martin², Beth Turrentine², Michelle Pomphrey², Justin Richards³, Lliam B Brannigan¹, Emily Schneiderman¹, Bhiken Naik¹, Michael Mazzeffi^{4

5}

Affiliations

¹ Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA.
² Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.
³ Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA.
⁴ Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA. syy4wa@uvahealth.org.
⁵ Department of Anesthesiology, University of Virginia Health, PO Box 800710, Charlottesville, VA, 22908, USA. syy4wa@uvahealth.org.

PMID: 40377892
DOI: 10.1007/s40615-025-02476-9

Racial and Ethnic Differences in Withdrawal of Life-Sustaining Treatment and Hospice Referral in Severe Traumatic Brain Injury

Erin Hennessey et al. J Racial Ethn Health Disparities. 2025.

. 2025 May 16.

doi: 10.1007/s40615-025-02476-9. Online ahead of print.

Authors

Erin Hennessey¹, Tamriage Martin², Beth Turrentine², Michelle Pomphrey², Justin Richards³, Lliam B Brannigan¹, Emily Schneiderman¹, Bhiken Naik¹, Michael Mazzeffi^{4

5}

Affiliations

¹ Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA.
² Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.
³ Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA.
⁴ Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA. syy4wa@uvahealth.org.
⁵ Department of Anesthesiology, University of Virginia Health, PO Box 800710, Charlottesville, VA, 22908, USA. syy4wa@uvahealth.org.

PMID: 40377892
DOI: 10.1007/s40615-025-02476-9

Abstract

Background: Patients with severe traumatic brain injury (TBI) frequently require surrogate decision-making including decisions about end-of-life care. Because prognostication in severe TBI remains challenging, there may be significant variation in surrogate decision-making. Our study aim was to explore differences in withdrawal of life-sustaining treatment (WLST) and hospice referral among patients of different races and ethnicities who had severe TBI.

Methods: A retrospective cohort study was performed using the Trauma Quality Programs Participant Use File from 2022. Patients with severe TBI were identified using diagnostic codes. Severe TBI was defined as Glasgow Coma Scale ≤ 8 at hospital admission. The study's primary outcomes were WLST and referral to hospice. Multivariable logistic regression models were fit to explore risk-adjusted associations between race and ethnicity, and WLST and hospice referral.

Results: There were 4121 patients included in the final study cohort. Among these, 57.4% were non-Hispanic White, 17.3% were non-Hispanic Black, 14.3% were Hispanic, and 11.0% were non-Hispanic patients of other races. Race and ethnicity were independently associated with WLST. Non-Hispanic Black patients had lower risk-adjusted odds of WLST compared to non-Hispanic White patients; OR = 0.49 (95% CI = 0.37 to 0.65, p < .001). Hispanic patients and non-Hispanic patients of other races also had lower risk-adjusted odds of WLST; OR = 0.59 (95% CI = 0.44 to 0.78, p < .001) and OR = 0.67 (95% CI = 0.49 to 0.90, p = .009). Non-Hispanic Black patients had lower risk-adjusted odds of hospice referral; OR = 0.42 (95% CI = 0.20 to 0.88, p = .02) compared to non-Hispanic White patients.

Conclusions: Patients of different races and ethnicities with severe TBI have different rates of WLST and hospice referral. Additional research is needed to better understand the reasons for differences in surrogate decision-making and WLST including the potential influence of culture, religion, socioeconomic status, and medical literacy.

Keywords: Brain injury; Disparities; End-of-life care; Hospice; Trauma.

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Conflict of interest statement

Declarations. Ethics Approval: The Institutional Review Board determined that the submitted study was non-human subjects research and granted a waiver of written consent. Competing Interests: None relevant to this work. MM has previously received consulting fees from Hemosonics, Octapharma, and Novo Nordisk. None of these consulting fees was related to the submitted work. Meeting: None.

References

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1. Andelic N, Howe EI, Hellstrom T, Sanchez MF, Lu J, Lovstad M, Roe C. Disability and quality of life 20 years after traumatic brain injury. Brain Behav. 2018;8:e01018. https://doi.org/10.1002/brb3.1018 . - DOI - PubMed - PMC
1. Graw JA, Burchard R. Completion rates of advance directives in a trauma emergency room: association with age. Emerg Med Int. 2021;2021:5537599. https://doi.org/10.1155/2021/5537599 . - DOI - PubMed - PMC

[1] Roozenbeek B, Chiu YL, Lingsma HF, Gerber LM, Steyerberg EW, Ghajar J, Maas AI. Predicting 14-day mortality after severe traumatic brain injury: application of the IMPACT models in the brain trauma foundation TBI-trac(R) New York State database. J Neurotrauma. 2012;29:1306–12. https://doi.org/10.1089/neu.2011.1988 . - DOI - PubMed - PMC

[2] Roozenbeek B, Chiu YL, Lingsma HF, Gerber LM, Steyerberg EW, Ghajar J, Maas AI. Predicting 14-day mortality after severe traumatic brain injury: application of the IMPACT models in the brain trauma foundation TBI-trac(R) New York State database. J Neurotrauma. 2012;29:1306–12. https://doi.org/10.1089/neu.2011.1988 . - DOI - PubMed - PMC

[3] Dawes AJ, Sacks GD, Cryer HG, Gruen JP, Preston C, Gorospe D, Cohen M, McArthur DL, Russell MM, Maggard-Gibbons M, Ko CY. Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: A propensity score–matched analysis. J Trauma Acute Care Surg. 2015;78(3):492–502. https://doi.org/10.1097/TA.0000000000000559 . - DOI - PubMed

[4] Dawes AJ, Sacks GD, Cryer HG, Gruen JP, Preston C, Gorospe D, Cohen M, McArthur DL, Russell MM, Maggard-Gibbons M, Ko CY. Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: A propensity score–matched analysis. J Trauma Acute Care Surg. 2015;78(3):492–502. https://doi.org/10.1097/TA.0000000000000559 . - DOI - PubMed

[5] Whitnall L, McMillan TM, Murray GD, Teasdale GM. Disability in young people and adults after head injury: 5–7 year follow up of a prospective cohort study. J Neurol Neurosurg Psychiatry. 2006;77:640–5. https://doi.org/10.1136/jnnp.2005.078246 . - DOI - PubMed - PMC

[6] Whitnall L, McMillan TM, Murray GD, Teasdale GM. Disability in young people and adults after head injury: 5–7 year follow up of a prospective cohort study. J Neurol Neurosurg Psychiatry. 2006;77:640–5. https://doi.org/10.1136/jnnp.2005.078246 . - DOI - PubMed - PMC

[7] Andelic N, Howe EI, Hellstrom T, Sanchez MF, Lu J, Lovstad M, Roe C. Disability and quality of life 20 years after traumatic brain injury. Brain Behav. 2018;8:e01018. https://doi.org/10.1002/brb3.1018 . - DOI - PubMed - PMC

[8] Andelic N, Howe EI, Hellstrom T, Sanchez MF, Lu J, Lovstad M, Roe C. Disability and quality of life 20 years after traumatic brain injury. Brain Behav. 2018;8:e01018. https://doi.org/10.1002/brb3.1018 . - DOI - PubMed - PMC

[9] Graw JA, Burchard R. Completion rates of advance directives in a trauma emergency room: association with age. Emerg Med Int. 2021;2021:5537599. https://doi.org/10.1155/2021/5537599 . - DOI - PubMed - PMC

[10] Graw JA, Burchard R. Completion rates of advance directives in a trauma emergency room: association with age. Emerg Med Int. 2021;2021:5537599. https://doi.org/10.1155/2021/5537599 . - DOI - PubMed - PMC

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Racial and Ethnic Differences in Withdrawal of Life-Sustaining Treatment and Hospice Referral in Severe Traumatic Brain Injury

Affiliations

Racial and Ethnic Differences in Withdrawal of Life-Sustaining Treatment and Hospice Referral in Severe Traumatic Brain Injury

Authors

Affiliations

Abstract

Conflict of interest statement

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Abstract

Conflict of interest statement

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