Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers.
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 were used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. chi, t tests, and multivariate analysis were 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), comorbidity (p = <0.001), and injury mechanism were associated with WOCO (p = 0.03). WOCO patients had higher New Injury Severity Score (p = <0.001), lower Glasgow Coma Scale motor scores (p = <0.001), and higher incidence of midline shift on head computed tomography (p = 0.01). Trauma center status (odds ratio, 1.56; 95% confidence interval, 1.06-2.30) and closed intensive care units (odds ratio, 1.53; 95% confidence interval, 1.03-2.25) were also predictive of a WOCO. There was a sizable variation (0%-16%) in the percentage of patients with WOCO across centers.


CONCLUSIONS
Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed intensive care units are predictive of a 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 a WOCO is applied to trauma patients.
Division of Trauma, Burns, and Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. zcooper@partners.org
Zara
Z
Cooper
Frederick P
FP
Rivara
Jin
J
Wang
Ellen J
EJ
MacKenzie
Gregory J
GJ
Jurkovich
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D016009:Chi-Square Distribution; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000592:standards / Q000639:trends; D008020:Life Support Care / Q000592:standards / Q000639:trends; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D011336:Probability; D011446:Prospective Studies; D012016:Reference Values; D016414:Resuscitation Orders; D018570:Risk Assessment; D014193:Trauma Centers / Q000592:standards* / Q000639:trends; D015599:Trauma Severity Indices; D028761:Withholding Treatment / Q000592:standards* / Q000639:trends; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy*; D055815:Young Adult