title: Contrasting patient, family, provider, and societal goals at the end of life complicate decision making and induce variability of care after trauma.
abstract: BACKGROUND
  End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost.
  
  
  METHODS
  An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based.
  
  
  RESULTS
  A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time.
  
  
  CONCLUSIONS
  Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered.
  
  
  METHODS
  Care management study, level IV.
authors: From the Division of Traumatology, Surgical Critical Care & Emergency Surgery (N.D.M., M.Z.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and Division of Acute Care Surgery (A.S., L.M., C.F., M.J.C., V.M., D.L., A.C.B., M.S.W.), Thomas Jefferson University, Philadelphia, Pennsylvania.
authors: Niels Douglas
authors: ND
authors: Martin
authors: Anthony
authors: A
authors: Stefanelli
authors: Laura
authors: L
authors: Methvin
authors: Charles
authors: C
authors: Fischer
authors: MayJean
authors: M
authors: Counsilman
authors: Vanessa
authors: V
authors: Mazandi
authors: Dean
authors: D
authors: Laganosky
authors: Muhammad
authors: M
authors: Zubair
authors: Alec C
authors: AC
authors: Beekley
authors: Michael S
authors: MS
authors: Weinstein
mesh_terms: D016223:Advance Directives; D003625:Data Collection; D003657:Decision Making; D005190:Family / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male; D011795:Surveys and Questionnaires; D013727:Terminal Care; D014193:Trauma Centers; D014194:Traumatology / Q000379:methods / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000628:therapy*