title: Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too?
abstract: OBJECTIVE
  We examined factors associated with withdrawal of care (WOC) in moderate-severe traumatic brain injury (msTBI) patients, and how WOC may affect short-term mortality and receipt of neurosurgery. Variability in msTBI-related outcome prognostication by clinicians from different specialties was also assessed.
  
  
  METHODS
  Rates of WOC, factors associated with WOC, and the relation between WOC and in-hospital case-fatality rate (CFR) and neurosurgery were determined in 232 prospectively enrolled msTBI patients in the ongoing OPTIMISM Study at a level-1 trauma center. In a concomitant web-based survey with clinical vignettes, outcome prognostication comfort, treatment aggressiveness, and WOC recommendations were examined among 106 respondents from neurology, neurocritical care, neurosurgery, trauma and anesthesia/critical care.
  
  
  RESULTS
  The average age of the study sample was 53 years, with a median Glasgow Coma Scale of 6. The in-hospital CFR was 36 and 68 % of patients had WOC. Factors independently associated with WOC were advanced age, pupillary reactivity, lower intensive care unit-length-of-stay, pre- and in-hospital cardiac arrest, herniation, intracranial pressure crisis, and pre-existing endocrine disease. Inclusion of WOC in our multivariable regression model predicting in-hospital CFRs negated all other variables. Survey results suggested that in younger patients, some clinicians prognosticated overly pessimistically based upon data available at the time of presentation.
  
  
  CONCLUSIONS
  In our msTBI cohort, WOC was the most important predictor of in-hospital mortality. We identified several important independent predictors of WOC. Large within-center variability in msTBI outcome prognostication with varying levels of possible clinical nihilism exists, which may form the basis of self-fulfilling prophecies.
authors.affiliation: Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Saef
authors.initials: S
authors.lastname: Izzy
authors.forename: Rebecca
authors.initials: R
authors.lastname: Compton
authors.forename: Raphael
authors.initials: R
authors.lastname: Carandang
authors.forename: Wiley
authors.initials: W
authors.lastname: Hall
authors.forename: Susanne
authors.initials: S
authors.lastname: Muehlschlegel
mesh_terms: D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000401:mortality* / Q000601:surgery / Q000628:therapy; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D028761:Withholding Treatment / Q000706:statistics & numerical data*; D000078329:Workforce