Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study
- Alexis F. Turgeon, MD MSc⇓,
- François Lauzier, MD MSc,
- Jean-François Simard, BSc,
- Damon C. Scales, MD PhD,
- Karen E.A. Burns, MD MSc,
- Lynne Moore, PhD,
- David A. Zygun, MD MSc,
- Francis Bernard, MD,
- Maureen O. Meade, MD MSc,
- Tran Cong Dung, MD MSc,
- Mohana Ratnapalan, HBSc,
- Stephanie Todd, BSc MBT,
- John Harlock, MD,
- Dean A. Fergusson, PhD
- for the Canadian Critical Care Trials Group
- From the Centre de Recherche du Centre hospitalier affilié universitaire de Québec–Hôpital de l’Enfant-Jésus, Traumatologie-Urgence-Soins Intensifs (Turgeon, Lauzier, Simard, Moore, Cong Dung); the Division of Critical Care Medicine (Turgeon, Lauzier), Department of Anesthesiology; the Department of Medicine (Lauzier); and the Department of Social and Preventive Medicine (Moore), Université Laval, Québec, Que.; the Department of Critical Care Medicine (Scales, Burns, Ratnapalan), University of Toronto, Toronto, Ont.; the Department of Critical Care Medicine (Zygun, Todd), University of Calgary, Calgary, Alta.; the Department of Internal Medicine (Bernard), Université de Montréal, Montréal, Que.; the Department of Critical Care Medicine (Meade) and the Department of Surgery (Harlock), McMaster University, Hamilton, Ont.; and the Centre for Transfusion and Critical Care Research (Fergusson), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ont.
- Correspondence to:
Dr. Alexis F. Turgeon, alexis.turgeon{at}fmed.ulaval.ca
Abstract
Background: Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine.
Methods: To evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale).
Results: We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%–35.2%) and ranged from 10.8% to 44.2% across centres (χ2 test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%–75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ2 test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care.
Interpretation: We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.
