Withdrawal of Life-Sustaining Therapy in Injured Patients: Variations Between Trauma Centers and Nontrauma Centers

Abstract

Background—We sought to identify patient and institutional variables predictive of a withdrawal of care order (WOCO) in trauma patients. We hypothesized that the frequency of WOCO would be higher at trauma centers. Methods—Data from the National Study on the Costs and Outcomes of Trauma (NSCOT) was used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. Chi-square, t-tests and multivariate analysis was used to identify variables predictive of WOCO. Results—Of 14,190 patients, 618 (4.4%) had WOCO, which accounted for 60.9% of patients who died in hospital. Age (p=<0.001), race (p=<0.001), co-morbidity (p=<0.001) and injury mechanism were associated with WOCO (p=0.03). WOCO patients had higher NISS (p=<0.001), lower GCS motor scores (p=<0.001) and higher incidence of midline shift on head CT (p=0.01). Trauma center status (OR 1.56 (95% CI 1.06,2.30)) and closed ICU (OR 1.53 (95% CI 1.03,2.25)) were also predictive of WOCO. There was sizeable variation (0 to 16%) in the percentage of patients with WOCO across centers. Conclusion—Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed ICU are predictive of WOCO, variation in the percentage of patients with WOCO across all centers speaks to the complexity of these decisions. Further investigation is needed to understand how WOCO is applied to trauma patients.