title: Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients.
abstract: OBJECTIVE
  Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities.
  
  
  METHODS
  We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours.
  
  
  RESULTS
  Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001).
  
  
  CONCLUSIONS
  Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.
authors.affiliation: Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, Department of Neurology, 660 South Euclid Ave Campus Box 8111, St Louis, MO 63110 United States. Electronic address: rubinm@me.com.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Rubin
authors.affiliation: Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, Department of Neurology, 660 South Euclid Ave Campus Box 8111, St Louis, MO 63110 United States.
authors.forename: Rajat
authors.initials: R
authors.lastname: Dhar
authors.affiliation: Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, Department of Neurology, 660 South Euclid Ave Campus Box 8111, St Louis, MO 63110 United States.
authors.forename: Michael N
authors.initials: MN
authors.lastname: Diringer
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001930:Brain Injuries / Q000208:ethnology*; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D044469:Racial Groups / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D015300:Ventilator Weaning / Q000706:statistics & numerical data*
keywords: Brain injury; Medical ethics; Racial disparity; Withdrawal of ventilation