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Original Investigation
June 17, 2020

Withdrawal of Life-Supporting Treatment in Severe Traumatic Brain Injury

Author Affiliations
  • 1Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina
  • 2Duke University School of Medicine, Duke University, Durham, North Carolina
  • 3Duke University Medical Center, Department of Population Health Sciences, Durham, North Carolina
  • 4Duke-Margolis Center for Health Policy, Durham, North Carolina
  • 5The Fuqua School of Business, Duke University, Durham, North Carolina
  • 6Duke University Medical Center, Department of Pediatrics, Durham, North Carolina
JAMA Surg. Published online June 17, 2020. doi:10.1001/jamasurg.2020.1790
Key Points

Question  Which factors are associated with the decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury in the US?

Findings  In this large, multicenter cohort study, race, geographic region, and payment status were significantly associated with the decision to withdraw LST. Associated clinical factors included older age, lower Glasgow Coma Scale score, functionally dependent health status, hematoma, dementia, and disseminated cancer.

Meaning  In addition to clinical factors, there is evidence for socioeconomic variation in the decision to withdraw LST in patients with severe traumatic brain injury.

Abstract

Importance  There are limited data on which factors affect the critical and complex decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury (sTBI).

Objective  To determine demographic and clinical factors associated with the decision to withdraw LST in patients with sTBI.

Design, Setting, and Participants  This retrospective analysis of inpatient data from more than 825 trauma centers across the US in theAmerican College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2015 included adult patients with sTBI and documentation of a decision regarding withdrawal of LST (WLST). Data analysis was conducted in September 2019.

Main Outcomes and Measures  Factors associated with WLST in sTBI.

Results  A total of 37931 patients (9817 women [25.9%]) were included in the multivariable analysis; 7864 (20.7%) had WLST. Black patients (4806 [13.2%]; odds ratio [OR], 0.66; 95% CI, 0.59-0.72; P < .001) and patients of other race (4798 [13.2%]; OR, 0.83; 95% CI, 0.76-0.91; P < .001) were less likely than white patients (26 864 [73.7%]) to have WLST. Patients from hospitals in the Midwest (OR, 1.12; 95% CI, 1.04-1.20; P = .002) or Northeast (OR, 1.23; 95% CI, 1.13-1.34; P < .001) were more likely to have WLST than patients from hospitals in the South. Patients with Medicare (OR, 1.55; 95% CI, 1.43-1.69; P < .001) and self-pay patients (OR, 1.36; 95% CI, 1.25-1.47; P < .001) were more likely to have WLST than patients with private insurance. Older patients and those with lower Glasgow Coma Scale scores, higher Injury Severity Scores, or craniotomy were generally more likely to have WLST. Withdrawal of LST was more likely for patients with functionally dependent health status (OR, 1.30; 95% CI, 1.08-1.58; P = .01), hematoma (OR, 1.19; 95% CI, 1.12-1.27; P < .001), dementia (OR, 1.29; 95% CI, 1.08-1.53; P = .004), and disseminated cancer (OR, 2.82; 95% CI, 2.07-3.82; P < .001) than for patients without these conditions.

Conclusions and Relevance  Withdrawal of LST is common in sTBI and socioeconomic factors are associated with the decision to withdraw LST. These results highlight the many factors that contribute to decision-making in sTBI and demonstrate that in a complex and variable disease process, variation based on race, payment, and region presents as a potential challenge.

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