Abstract
Background and objectives
Withdrawal of life-sustaining treatment (WOLST) is a common factor leading to death in traumatic brain injury (TBI). Recent guidelines have supported delaying WOLST given data suggesting that even patients with severe injuries may have meaningful recovery. However, temporal trends in WOLST are not well described. Here we investigate trends in WOLST among patients with TBI.Methods
We performed a retrospective cohort study using data from the American College of Surgeons Trauma Quality Program (ACS-TQP) between 2013 and 2023. We included all adults aged 18+ years with TBI defined by ICD-9/ICD-10-CM codes who died before discharge from the index hospitalization. We captured demographic factors including age, race/ethnicity, and comorbidities, as well as hospital/outcome variables including interfacility transfer, hospital size and teaching status, and major hospital complications. WOLST is recorded by each participating trauma center and captured as a discrete variable in the ACS-TQP. For each year, we calculated proportions of death after WOLST as well as time to WOLST. We repeated the analyses, including only patients with isolated TBI and stratifying by TBI severity.Results
We identified 3,864,837 patients with TBI from 2013 to 2023 of whom 164,860 (4.3%) died during index hospitalization and had documented WOLST status. Of these, 93,664 (56.8%) died after WOLST. In total, 31.7% of the WOLST group and 27.5% of the no WOLST group were female. Patients with WOLST were older with median age 68 (IQR 51-79) vs 53 (IQR 31-72) and were more likely to have preexisting comorbidities. The proportion of deaths with WOLST decreased from 60.7% (95% CI 59.4%-62.0%) in 2013 to 56.1% (95% CI 55.4%-56.8%) in 2023 (annual percent change = -0.8%; 95% CI -1.4% to -0.2%; p = 0.010). Time to WOLST increased from a mean of 5.7 days (SD 7.4) in 2013 to 7.1 days (SD 10.0) in 2023 (p p Discussion
The proportion of trauma patients with TBI who died after WOLST decreased modestly from 2013 to 2023 while time to WOLST increased. Although these may reflect shifting attitudes toward prognostication, WOLST nonetheless remains common and occurs early among patients with TBI.