Trauma, Gender, and End-of-Life Care: A Propensity-Matched Cohort Study Analyzing Disparities in Withdrawal of Life Support

Abstract

Introduction: Men are known to have more severe injuries at younger ages compared to women. However, the relationship between gender and other sociodemographic factors in the context of end-of-life care after traumatic injuries is not well understood.

Methods: This retrospective observational cohort study utilized data from the American College of Surgeons Trauma Quality Programs in 2022 and included all patients who were 18 y or older while those with missing information on withdrawal of life-sustaining treatment (WLST) were excluded. Descriptive analysis and multiple logistic regression, following propensity score nearest neighbor matching, were performed to determine the association between WLST and gender after traumatic injury.

Results: Among the 843,135 patients who met the inclusion criteria, 43.6% were female. Compared to females, males were younger. A higher proportion of females had Medicare than males (56.7% versus 31.1%). In contrast, other insurance such as private, Medicaid, self-pay, and others were comparatively more frequently utilized by males. Among injury characteristics, assault was more common among males compared to females (11.0% versus 3.0%). Not surprisingly, initial Glasgow Coma Scale and injury severity were comparatively severe among males. WLST was reported in 2.5% of males and 1.9% of females. After propensity score matching, compared to males of age 18-35 y, males of increasing age had higher odds of WLST. Similar trends were seen among females of increasing age compared to males aged 18-35 y. However, the magnitude of the estimates was higher among males. Of note, compared to private insurance, those with Medicare were likelier to have WLST.

Conclusions: One in every two patients who died after traumatic injury had WLST, whereas males have an increased likelihood of WLST despite matching and adjusting for injury site and severity. These findings suggest a need for policies addressing demographic and insurance-related disparities to ensure equitable end-of-life care across diverse patient populations.

Keywords: Acute critical care; Advance directive; End-of-life care; Gender; Sociodemographic factor; Trauma.