title: Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study.
abstract: BACKGROUND
  Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine.
  
  
  METHODS
  To evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale).
  
  
  RESULTS
  We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%-35.2%) and ranged from 10.8% to 44.2% across centres (χ(2) test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%-75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ(2) test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care.
  
  
  CONCLUSIONS
  We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.
authors.affiliation: Centre de Recherche du Centre hospitalier affilié universitaire de Québec-Hôpital de l'Enfant-Jésus, Traumatologie-Urgence-Soins Intensifs, Université Laval, Québec, Que. alexis.turgeon@fmed.ulaval.ca
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
authors.forename: François
authors.initials: F
authors.lastname: Lauzier
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Simard
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
authors.forename: Karen E A
authors.initials: KE
authors.lastname: Burns
authors.forename: Lynne
authors.initials: L
authors.lastname: Moore
authors.forename: David A
authors.initials: DA
authors.lastname: Zygun
authors.forename: Francis
authors.initials: F
authors.lastname: Bernard
authors.forename: Maureen O
authors.initials: MO
authors.lastname: Meade
authors.forename: Tran Cong
authors.initials: TC
authors.lastname: Dung
authors.forename: Mohana
authors.initials: M
authors.lastname: Ratnapalan
authors.forename: Stephanie
authors.initials: S
authors.lastname: Todd
authors.forename: John
authors.initials: J
authors.lastname: Harlock
authors.forename: Dean A
authors.initials: DA
authors.lastname: Fergusson
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000401:mortality* / Q000628:therapy*; D002170:Canada / Q000453:epidemiology; D016638:Critical Illness; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008020:Life Support Care; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data; D055815:Young Adult