Withdrawal of Life-Sustaining Treatment for Pediatric Patients With Severe Traumatic Brain Injury
Armaan K Malhotra1,2,3, Husain Shakil1,2,3, Christopher W Smith1,2
1Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada.
Insights
Decisions to withdraw life-sustaining treatment for pediatric severe traumatic brain injury (TBI) vary significantly between trauma centers. This variation is linked to differences in adjusted mortality rates, highlighting the need for standardized guidelines.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Health services research
Background:
- Withdrawing life-sustaining treatment in pediatric severe traumatic brain injury (TBI) presents complex ethical and clinical challenges.
- Limited evidence exists on current practices and variability in withdrawal of life-sustaining treatment (WLST) decisions for pediatric TBI patients.
- Lack of standardized guidelines likely contributes to inconsistent WLST practices across trauma centers.
Purpose of the Study:
- To identify factors influencing WLST decisions in North American pediatric severe TBI cases.
- To quantify the variability in WLST practices among different trauma centers.
- To explore the association between WLST practice variation and patient outcomes.
Main Methods:
- Retrospective cohort study utilizing data from the American College of Surgeons Trauma Quality Improvement Program (2017-2020).
- Included pediatric patients (<19 years) with severe TBI and documented WLST decisions.
- Multilevel logistic regression and median odds ratio used to analyze patient, injury, and hospital factors and between-center variability.
Main Results:
- Out of 9803 children with severe TBI, 1003 (10.2%) had WLST decisions.
- Younger age (<3 years), severe intracranial/extracranial injuries, and firearm-related injuries increased WLST likelihood.
- A median odds ratio of 1.54 indicated significant residual variation in WLST practices between centers.
- Centers with higher propensity for WLST had higher adjusted mortality rates (OR, 1.66).
Conclusions:
- Patient and injury characteristics influence WLST decisions in pediatric severe TBI.
- Significant variation in WLST practices exists between trauma centers, even after adjusting for case mix.
- This practice variation is associated with differences in risk-adjusted mortality, underscoring the need for clinical guidelines.
Importance:
The decision to withdraw life-sustaining treatment for pediatric patients with severe traumatic brain injury (TBI) is challenging for clinicians and families with limited evidence quantifying existing practices. Given the lack of standardized clinical guidelines, variable practice patterns across trauma centers seem likely.
Objective:
To evaluate the factors influencing decisions to withdraw life-sustaining treatment across North American trauma centers for pediatric patients with severe TBI and to quantify any existing between-center variability in withdrawal of life-sustaining treatment practices.
Design, Setting, And Participants:
This retrospective cohort study used data collected from 515 trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. Pediatric patients younger than 19 years with severe TBI and a documented decision for withdrawal of life-sustaining treatment were included. Data were analyzed from January to May 2023.
Main Outcomes And Measures:
A random intercept multilevel logistic regression model was used to quantify patient, injury, and hospital characteristics associated with the decision to withdraw life-sustaining treatment; the median odds ratio was used to characterize residual between-center variability. Centers were ranked by their conditional random intercepts and quartile-specific adjusted mortalities were computed.
Results:
A total of 9803 children (mean [SD] age, 12.6 [5.7]; 2920 [29.8%] female) with severe TBI were identified, 1003 of whom (10.2%) had a documented decision to withdraw life-sustaining treatment. Patient-level factors associated with an increase in likelihood of withdrawal of life-sustaining treatment were young age (younger than 3 years), higher severity intracranial and extracranial injuries, and mechanism of injury related to firearms. Following adjustment for patient and hospital attributes, the median odds ratio was 1.54 (95% CI, 1.46-1.62), suggesting residual variation in withdrawal of life-sustaining treatment between centers. When centers were grouped into quartiles by their propensity for withdrawal of life-sustaining treatment, adjusted mortality was higher for fourth-quartile compared to first-quartile centers (odds ratio, 1.66; 95% CI, 1.45-1.88).
Conclusions And Relevance:
Several patient and injury factors were associated with withdrawal of life-sustaining treatment decision-making for pediatric patients with severe TBI in this study. Variation in withdrawal of life-sustaining treatment practices between trauma centers was observed after adjustment for case mix; this variation was associated with differences in risk-adjusted mortality rates. Taken together, these findings highlight the presence of inconsistent approaches to withdrawal of life-sustaining treatment in children, which speaks to the need for guidelines to address this significant practice pattern variation.
