Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients

Michael D Sullivan; Natthida Owattanapanich; Morgan Schellenberg; Kazuhide Matsushima; Meghan R Lewis; Lydia Lam; Matthew Martin; Kenji Inaba

doi:10.1016/j.injury.2023.111088

Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients

Injury. 2023 Dec;54(12):111088. doi: 10.1016/j.injury.2023.111088. Epub 2023 Oct 5.

Authors

Michael D Sullivan¹, Natthida Owattanapanich¹, Morgan Schellenberg¹, Kazuhide Matsushima¹, Meghan R Lewis¹, Lydia Lam¹, Matthew Martin¹, Kenji Inaba²

Affiliations

¹ Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
² Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA. Electronic address: kenji.inaba@med.usc.edu.

PMID: 37833232
DOI: 10.1016/j.injury.2023.111088

Abstract

Introduction: Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST.

Methods: The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients.

Results: Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h.

Conclusions: More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.

Keywords: Associated injury score (AIS); Glasgow coma score (GCS); Withdrawal of life sustaining treatment (WLST).

MeSH terms

Aged
Aged, 80 and over
Female
Glasgow Coma Scale
Humans
Injury Severity Score
Male
Retrospective Studies
Risk Factors
Withholding Treatment
Wounds, Nonpenetrating*
Wounds, Penetrating*