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Withholding and withdrawal of life-sustaining therapy in 8569 trauma patients: A multicentre, analytical registry
Malik Haddam1, Laura Kubacsi, Sophie Hamada
1From the Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Department of Anaesthesia and Intensive Care, Hôpital Nord (MH, LK, LZ, ML), Support Unit for Clinical Research and Economic Evaluation, Assistance Publique-Hôpitaux de Marseille - CERESS, Aix Marseille University, Marseille (NR), Kremlin Bicêtre University Hospital, Assistance Publique Hôpitaux de Paris, Department of Anaesthesia and Intensive Care, Le Kremlin-Bicêtre (AH), Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Pitié Salpêtrière University Hospital (AJ), Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou University Hospital, Paris (SH, ML), Department of Anaesthesia and Intensive Care, Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Créteil (OL), Department of Anaesthesiology and Critical Care Medicine, DMU Parabol, Beaujon Hospital, APHP. Nord-Université de Paris, 100 Bd du General Leclerc 92110 Clichy (MHo), Department of Anaesthesia and Intensive Care, Clamart Army Training Hospital Percy, Clamart (MB), Toulon Army Training Hospital Sainte-Anne, Toulon (MC), Department of Anaesthesia and Intensive Care, Toulouse University Hospital, Toulouse (HV), Department of Anesthesia and Critical Care Medicine, Université de Lorraine, CHRU Nancy, Nancy (GA), Lille University Hospital, Pôle de l'Urgence, Pôle d'Anesthésie Réanimation, Lille (DG), Department of Anaesthesia and Intensive Care, Reims University Hospital, Reims (MLec), Department of Anaesthesia and Intensive Care, Caen University Hospital, Caen (JLH) and Department of Anaesthesia and Perioperative Medicine, Strasbourg University Hospital, Strasbourg, France (JP).
Background:
This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision.
Design:
This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were pro-spectively included.
Results:
Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death.
Conclusion:
Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.
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