The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment.
Journal
The journal of trauma and acute care surgery
ISSN: 2163-0763
Titre abrégé: J Trauma Acute Care Surg
Pays: United States
ID NLM: 101570622
Informations de publication
Date de publication:
01 06 2023
01 06 2023
Historique:
medline:
24
5
2023
pubmed:
12
3
2023
entrez:
11
3
2023
Statut:
ppublish
Résumé
There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients. This retrospective analysis of the American College of Surgeons- Trauma Quality Improvement Program (2017-2019) included all severely injured (Injury Severity Score >15) geriatric trauma patients (≥65 years). Multivariable logistic regression was performed to identify independent predictors of WLST. There were 155,583 patients included. Mean age was 77 ± 7 years, 55% were male, 97% sustained blunt injury, and the median Injury Severity Score was 17 [16-25]. Overall WLST rate was 10.8%. On MLR analysis, increasing age (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.33-1.37; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.09-1.18; p < 0.001), White race (aOR, 1.44; 95% CI, 1.36-1.52; p < 0.001), frailty (aOR, 1.42; 95% CI, 1.34-1.50; p < 0.001), government insurance (aOR, 1.27; 95% CI, 1.20-1.33; p < 0.001), presence of advance directive limiting care (aOR, 2.55; 95% CI, 2.40-2.70; p < 0.001), severe traumatic brain injury (aOR, 1.80; 95% CI, 1.66-1.95; p < 0.001), ventilator requirement (aOR, 12.73; 95% CI, 12.09-13.39; p < 0.001), and treatment at higher level trauma centers (Level I aOR, 1.49; 95% CI, 1.42-1.57; p < 0.001; Level II aOR, 1.43; 95% CI, 1.35-1.51; p < 0.001) were independently associated with higher odds of WLST. Our results suggest that nearly one in 10 severely injured geriatric trauma patients undergo WLST. Multiple patient and hospital related factors contribute to decision making and directed efforts are necessary to create a more standardized process. Prognostic and Epidemiological; Level III.
Sections du résumé
BACKGROUND
There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients.
METHODS
This retrospective analysis of the American College of Surgeons- Trauma Quality Improvement Program (2017-2019) included all severely injured (Injury Severity Score >15) geriatric trauma patients (≥65 years). Multivariable logistic regression was performed to identify independent predictors of WLST.
RESULTS
There were 155,583 patients included. Mean age was 77 ± 7 years, 55% were male, 97% sustained blunt injury, and the median Injury Severity Score was 17 [16-25]. Overall WLST rate was 10.8%. On MLR analysis, increasing age (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.33-1.37; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.09-1.18; p < 0.001), White race (aOR, 1.44; 95% CI, 1.36-1.52; p < 0.001), frailty (aOR, 1.42; 95% CI, 1.34-1.50; p < 0.001), government insurance (aOR, 1.27; 95% CI, 1.20-1.33; p < 0.001), presence of advance directive limiting care (aOR, 2.55; 95% CI, 2.40-2.70; p < 0.001), severe traumatic brain injury (aOR, 1.80; 95% CI, 1.66-1.95; p < 0.001), ventilator requirement (aOR, 12.73; 95% CI, 12.09-13.39; p < 0.001), and treatment at higher level trauma centers (Level I aOR, 1.49; 95% CI, 1.42-1.57; p < 0.001; Level II aOR, 1.43; 95% CI, 1.35-1.51; p < 0.001) were independently associated with higher odds of WLST.
CONCLUSION
Our results suggest that nearly one in 10 severely injured geriatric trauma patients undergo WLST. Multiple patient and hospital related factors contribute to decision making and directed efforts are necessary to create a more standardized process.
LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level III.
Identifiants
pubmed: 36899461
doi: 10.1097/TA.0000000000003924
pii: 01586154-202306000-00005
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
778-783Informations de copyright
Copyright © 2023 American Association for the Surgery of Trauma.
Références
Mccusker A, Khan M, Kulvatunyou N, Zeeshan M, Sakran JV, Hayek H, et al. Sarcopenia defined by a computed tomography estimate of the psoas muscle area does not predict frailty in geriatric trauma patients. Am J Surg . 2019;218(2):261–265.
Trunkey DD, Cahn RM, Lenfesty B, Mullins R. Management of the geriatric trauma patient at risk of death: therapy withdrawal decision making. Arch Surg . 2000;135(1):34–38.
Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Hashmi A, Green DJ, et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. JAMA Surg . 2014;149(8):766–772.
Williamson T, Ryser MD, Ubel PA, Abdelgadir J, Spears CA, Liu B, et al. Withdrawal of life-supporting treatment in severe traumatic brain injury. JAMA Surg . 2020;155(8):723–731.
Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma Acute Care Surg . 2009;67(2):341–348.
Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. J Surg Res . 2013;183(1):104–110.
Plaisier BR, Blostein PA, Hurt KJ, Malangoni MA. Withholding/withdrawal of life support in trauma patients: is there an age bias? Am Surg . 2002;68(2):159–162.
Cooper Z, Rivara FP, Wang J, MacKenzie EJ, Jurkovich GJ. Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers. J Trauma . 2009;66(5):1327–1335.
Manara AR, Pittman JA, Braddon FE. Reasons for withdrawing treatment in patients receiving intensive care. Anaesthesia . 1998;53(6):523–528.
Hornor MA, Byrne JP, Engelhardt KE, Nathens AB. Examining racial disparities in the time to withdrawal of life-sustaining treatment in trauma. J Trauma Acute Care Surg . 2018;84(4):590–597.
Qureshi AI, Adil MM, Suri MF. Rate of use and determinants of withdrawal of care among patients with subarachnoid hemorrhage in the United States. World Neurosurg . 2014;82(5):e579–e584.
Joseph B, Pandit V, Rhee P, Aziz H, Sadoun M, Wynne J, et al. Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer? J Trauma Acute Care Surg . 2014;76(1):196–200.
Joseph B, Orouji Jokar T, Hassan A, Azim A, Mohler MJ, Kulvatunyou N, et al. Redefining the association between old age and poor outcomes after trauma: the impact of frailty syndrome. J Trauma Acute Care Surg . 2017;82(3):575–581.
Montgomery CL, Rolfson DB, Bagshaw SM. Frailty and the association between long-term recovery after intensive care unit admission. Crit Care Clin . 2018;34(4):527–547.
DeMario BS, Stanley SP, Truong EI, Ladhani HA, Brown LR, Ho VP, et al. Predictors for withdrawal of life-sustaining therapies in patients with traumatic brain injury: a retrospective trauma quality improvement program database study. Neurosurgery . 2022;91(2):e45–e50.
Kirchhoff KT, Anumandla PR, Foth KT, Lues SN, Gilbertson-White SH. Documentation on withdrawal of life support in adult patients in the intensive care unit. Am J Crit Care . 2004;13(4):328–334.
Gerstel E, Engelberg RA, Koepsell T, Curtis JR. Duration of withdrawal of life support in the intensive care unit and association with family satisfaction. Am J Respir Crit Care Med . 2008;178(8):798–804.
American College of Surgeons Committee on Trauma. Resources for optimal care of the injured patient. https://www.facs.org/media/yu0laoqz/resources-for-optimal-care.pdf . Published 2014. Accessed December 24, 2022.
ACS TQIP Palliative Care Best Practices Guidlines. Available at: https://www.facs.org/quality-programs/trauma/quality/best-practices-guidelines/ . Published October 2013. Accessed December 24, 2022.
Siddiqui MF, Holley JL. Residents’ practices and perceptions about do not resuscitate orders and pronouncing death: an opportunity for clinical training. Am J Hosp Palliat Care . 2011;28(2):94–97.