Withdrawal of life-supporting treatment in severe traumatic brain injury

Factors that influence the decision for withdrawal of life-supporting treatment (WLST) in patients with severe traumatic brain injury (sTBI) are incompletely understood.

The authors conducted a retrospective cohort study using the 2016-2022 American College of Surgeons Trauma Quality Programs database to identify demographic and clinical factors associated with the decision for WLST in patients with sTBI. Multivariable logistic regression analysis was conducted. Hospital length of stay (LOS), intensive care unit LOS, number of days on a ventilator, and disposition outcomes were compared between patients with and without WLST.

A total of 202,160 patients with sTBI were identified, of whom 44,341 (21.9%) had WLST. The risk of WLST increased with age, with patients > 75 years of age (adjusted odds ratio [aOR] 5.82, 95% CI 5.51-6.14; p < 0.001) being at the highest risk of having WLST. Black (aOR 0.59, 95% CI 0.57-0.62; p < 0.001) and Hispanic (aOR 0.76, 95% CI 0.73-0.80; p < 0.001) patients had lower odds of WLST. Patients with Medicare had significantly higher odds of having WLST (aOR 1.39, 95% CI 1.33-1.45; p < 0.001) compared to patients with private insurance. The risk of WLST decreased with increasing Glasgow Coma Scale (GCS) scores; patients with a GCS score of 7 or 8 were the least likely to have WLST (aOR 0.65, 95% CI 0.62-0.67; p < 0.001). Patients with one (aOR 1.89, 95% CI 1.80-1.99; p < 0.001) or two (aOR 2.46, 95% CI 2.38-2.53; p < 0.001) nonreactive pupils were more likely to have WLST. Patients with no midline shift (aOR 0.58, 95% CI 0.56-0.59; p < 0.001) were less likely to have WLST. Patients with penetrating injuries (aOR 1.43, 95% CI 1.33-1.53; p < 0.001) had significantly higher odds of WLST compared to those with blunt injuries. On average, patients with WLST had a considerably shorter hospital LOS (6.2 ± 8.4 days vs 16.6 ± 20.3 days) compared with no-WLST patients.

WLST in sTBI patients is associated with various features, including patient age, race, and insurance status. Further exploration is needed to fully understand the factors that impact the decision for WLST, with the aim of improving patient outcomes and care across socioeconomic divides.