title: Timing of withdrawal of life-sustaining therapies in severe traumatic brain injury: Impact on overall mortality.
abstract: BACKGROUND
  The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality.
  
  
  METHODS
  This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75th percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013 were involved. The cohort included 17,505 patients with severe isolated TBI.
  
  
  RESULTS
  One hundred eight centers were classified as early centers. The 75th percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted odds ratio, 0.95; 95% confidence interval, 0.83-1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (AIS) score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions, and signs of compressed or absent basal cisterns.
  
  
  CONCLUSIONS
  Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource use.
  
  
  METHODS
  Prognostic and epidemiologic study, level III.
authors.affiliation: From the Department of Critical Care Medicine (V.A.M., G.D.R., B.H.C., D.C.S.), Sunnybrook Research Institute (A.S.A., W.X., D.G.R., B.H.C., D.C.S., A.B.N.), and Department of Surgery (D.C.S.), Sunnybrook Health Sciences Center; and Department of Anesthesia (B.H.C.), University of Toronto, Toronto, Ontario, Canada.
authors.forename: Victoria A
authors.initials: VA
authors.lastname: McCredie
authors.forename: Aziz S
authors.initials: AS
authors.lastname: Alali
authors.forename: Wei
authors.initials: W
authors.lastname: Xiong
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Rubenfeld
authors.forename: Brian H
authors.initials: BH
authors.lastname: Cuthbertson
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000328:Adult; D061906:Advanced Trauma Life Support Care / Q000379:methods*; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009864:Ontario / Q000453:epidemiology; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D028761:Withholding Treatment / Q000639:trends*