Racial and Ethnic Differences in Withdrawal of Life-Sustaining Treatment and Hospice Referral in Severe Traumatic...

Patients with severe traumatic brain injury (TBI) frequently require surrogate decision-making including decisions about end-of-life care. Because prognostication in severe TBI remains challenging, there may be significant variation in surrogate decision-making. Our study aim was to explore differences in withdrawal of life-sustaining treatment (WLST) and hospice referral among patients of different races and ethnicities who had severe TBI.

A retrospective cohort study was performed using the Trauma Quality Programs Participant Use File from 2022. Patients with severe TBI were identified using diagnostic codes. Severe TBI was defined as Glasgow Coma Scale ≤ 8 at hospital admission. The study's primary outcomes were WLST and referral to hospice. Multivariable logistic regression models were fit to explore risk-adjusted associations between race and ethnicity, and WLST and hospice referral.

There were 4121 patients included in the final study cohort. Among these, 57.4% were non-Hispanic White, 17.3% were non-Hispanic Black, 14.3% were Hispanic, and 11.0% were non-Hispanic patients of other races. Race and ethnicity were independently associated with WLST. Non-Hispanic Black patients had lower risk-adjusted odds of WLST compared to non-Hispanic White patients; OR = 0.49 (95% CI = 0.37 to 0.65, p < .001). Hispanic patients and non-Hispanic patients of other races also had lower risk-adjusted odds of WLST; OR = 0.59 (95% CI = 0.44 to 0.78, p < .001) and OR = 0.67 (95% CI = 0.49 to 0.90, p = .009). Non-Hispanic Black patients had lower risk-adjusted odds of hospice referral; OR = 0.42 (95% CI = 0.20 to 0.88, p = .02) compared to non-Hispanic White patients.

Patients of different races and ethnicities with severe TBI have different rates of WLST and hospice referral. Additional research is needed to better understand the reasons for differences in surrogate decision-making and WLST including the potential influence of culture, religion, socioeconomic status, and medical literacy.