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Factors Associated with the Withdrawal of Life-Sustaining Therapies in Patients with Severe Traumatic Brain Injury: A Multicenter Cohort Study

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Abstract

Purpose

To identify factors associated with decisions to withdraw life-sustaining therapies in patients with severe traumatic brain injury (TBI).

Materials and Methods

We conducted a 2-year multicenter retrospective cohort study (2005–2006) in mechanically ventilated patients aged 16 years and older admitted to the intensive care units (ICUs) of six Canadian level I trauma centers following severe TBI. One hundred and twenty charts were randomly selected at each center (n = 720). Data on ICU management strategies, patients’ clinical condition, surgical procedures, diagnostic imaging, and decision to withdraw life-sustaining therapies were collected. The association of factors pertaining to the injury, interventions, and management strategies with decisions to withdraw life-sustaining therapies was evaluated among non-survivors.

Results

Among the 228 non-survivors, 160 died following withdrawal of life-sustaining therapies. Patients were predominantly male (69.7 %) with a mean age of 50.7 (±21.7) years old. Brain herniation was more often reported in patients who died following decisions to withdraw life-sustaining therapies (odds ratio [OR] 2.91, 95 % confidence interval [CI] 1.16–7.30, p = 0.02) compared to those who died due to other causes (e.g., cardiac arrest, shock, etc.). Epidural hematomas (OR 0.18, 95 % CI 0.06–0.56, p < 0.01), craniotomies (OR 0.12, 95 % CI 0.02–0.68, p = 0.02), and other non-neurosurgical procedures (OR 0.08, 95 % CI 0.02–0.43, p < 0.01) were less often associated with death following withdrawal of life-sustaining therapies than death from other causes.

Conclusions

Death following decisions to withdraw life-sustaining therapies is associated with specific patient and clinical factors, and the intensity of care.

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Acknowledgments

The authors would like to thank Tran Cong Dung MD, MSc; Mohana Ratnapalan HBSc, Stephanie Todd BSc, MBT, John Harlock MD, Frédéric Morin RN and David Simonyan MD MSc, for their help in data acquisition; Valérie Murat MSc for her participation in the data cleaning process; Mrs. Valérie Boucher for her secretarial assistance. This work was presented in part at the Intensive Care and Emergency Medicine Symposium (Brussels, Belgium, March 2011). The work was supported in part by the Fondation de lHôpital de lEnfant-Jésus (Enfant-Jésus Hospital Foundation) who had no role in any part of conduct of the study or preparation of the manuscript. Drs. Turgeon and Lauzier are recipients of a Research Career Award from the Fonds de Recherche Québec-Santé (FRQ-S). Drs. Moore, Scales, and Fergusson are recipients of New Investigator Awards from the Canadian Institutes for Health Research (CIHR). Dr. Zarychanski is a recipient of a CIHR RCT Mentorship Award. Dr. Burns holds a Clinician Scientist Phase 2 Award from the CIHR.

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Correspondence to Alexis F. Turgeon.

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This study was performed in six level I trauma centers in Canada: Québec (Centre Hospitalier Affilié Universitaire de Québec—Hôpital de l’Enfant-Jésus, Hôpital du Sacré-Coeur de Montréal), Ontario (Hamilton General Hospital, Sunnybrook Health Science Centre, St-Michael’s Hospital); Alberta (Foothill Medical Centre).

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Côte, N., Turgeon, A.F., Lauzier, F. et al. Factors Associated with the Withdrawal of Life-Sustaining Therapies in Patients with Severe Traumatic Brain Injury: A Multicenter Cohort Study. Neurocrit Care 18, 154–160 (2013). https://doi.org/10.1007/s12028-012-9787-9

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