Factors Influencing End-of-Life Decisions in Cancer Patients After Traumatic Injuries

Abstract

Introduction: Severe traumatic injuries are frequently associated with poor outcomes, and withdrawal of life-sustaining treatment (WLST) after traumatic brain injury is common. However, the association between WLST and pre-existing cancer in all trauma patients remains underexplored.

Methods: This retrospective cohort study analyzed data from the American College of Surgery Trauma Quality Programs in 2022. Patients aged 18 y or older with information on pre-existing disseminated cancer and chemotherapy status at the time of trauma were included. Descriptive statistics and multiple logistic regression, combined with propensity score matching, were used to assess the association between WLST and pre-existing cancer after traumatic injury.

Results: A total of 936,410 patients met the study criteria. Of these, 3827 (0.4%) were undergoing chemotherapy without metastatic cancer, 1528 (0.2%) had metastatic cancer but were not receiving chemotherapy, while 5399 (0.6%) were on chemotherapy. Significant differences in patient demographics, injury characteristics, and outcomes were observed across these groups. After matching on age, sex, race and ethnicity, insurance, injury severity, region and type, advance directives (ADs), functional dependence, prehospital cardiac arrest, and initial Glasgow Coma Scale, the adjusted odds ratio for WLST was 2.02 (95% CI: 1.39-2.95) for patients with metastatic cancer not on chemotherapy and 2.47 (95% confidence interval [CI]: 1.78-3.42) for patients with metastatic cancer on chemotherapy, compared to patients without cancer. Severe injuries were associated with 2.83 times higher odds of WLST (95% CI: 2.42-3.71) compared to mild injuries. Patients with chest, abdominal, and extremity injuries had lower odds of WLST compared to head and neck injuries. The presence of ADs limiting care was strongly associated with WLST (adjusted odds ratio: 3.62, 95% CI: 2.91-4.51).

Conclusions: Patients with metastatic cancer, regardless of chemotherapy status, had up to three times higher odds of WLST after traumatic injury. The presence of ADs was also strongly linked to increased WLST, emphasizing the importance of patient preferences and personalized care approaches in end-of-life decisions for cancer patients in trauma settings.

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