title: Intensity of treatment, end-of-life care, and mortality for older patients with severe traumatic brain injury.
abstract: The Eastern Association for the Surgery of Trauma (EAST) recommends that clinicians consider limiting further aggressive treatment in geriatric patients with severe traumatic brain injury (TBI) who do not improve in 72 hours (nonresponders) owing to their poor prognosis. However, little is known about how these guidelines are followed in practice. This study compared mortality and patient care among geriatric patients with severe TBI classified as "responders" and "nonresponders" 72 hours after injury.
  
  
  
  Retrospective review of patients 65 years or older at a Level I trauma center with severe TBI (GCS < 8) from 2011 to 2014. We compared in-hospital mortality, end-of-life (EOL) decision making, discharge functional status, and 12-month survival in responders (GCS > 8 at 72 hours) and nonresponders (GCS ≤ 8 at 72 hours).
  
  
  
  Of 90 patients, 29 (32%) died within 3 days of injury, 29 (32%) were nonresponders, and 32 (34%) were responders. An additional 19 patients (21%) died before hospital discharge, of whom 17 (89%) were nonresponders. Nonresponders had higher odds of in-hospital death (odds ratio, 31.8; 95% confidence interval [CI], 3.71-272.9; p = 0.002). Family meetings to discuss goals of care were more common in the nonresponder group (p < 0.001) and fewer nonresponders were full code at discharge or death (p < 0.001). There were no significant differences in functional status at discharge. Among patients discharged alive, there were no differences in 12-month survival.
  
  
  
  The responder/nonresponder dichotomy identifies patients with higher in-hospital mortality outcomes and is associated with differences in EOL decision making. However, functional impairment and poor survival were prevalent, irrespective of neurologic status at 72 hours.
  
  
  
  Prognostic/epidemiologic study, level III; therapeutic study, level IV.
authors.affiliation: From the Center for Surgery and Public Health (E.J.L., E.B.S., A.S., A.H.H., Z.C.), Brigham and Women's Hospital, Boston, MA; Department of Surgery (E.J.L.), Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ; Population Health Management, Department of Clinical Affairs (K.J.W.), Medical College of Wisconsin, Milwaukee, WI; Department of Surgery (E.B.S., K.H., A.S., A.H.H., Z.C.), Brigham and Women's Hospital, Boston, MA; and Surgical ICU Translational Research (STAR) Center (K.H.), Brigham and Women's Hospital, Boston, MA.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Lilley
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: Williams
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.forename: Khaled
authors.initials: K
authors.lastname: Hammouda
authors.forename: Ali
authors.initials: A
authors.lastname: Salim
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.forename: Zara
authors.initials: Z
authors.lastname: Cooper
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000070642:Brain Injuries, Traumatic / Q000401:mortality* / Q000628:therapy*; D003657:Decision Making; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D012042:Registries; D012189:Retrospective Studies; D013727:Terminal Care; D014193:Trauma Centers