Predictors of End-of-Life Care in Nonelderly Adults With Severe Traumatic Brain Injury

Introduction: Older age is a well-established risk factor for withdrawal of life-sustaining therapy (WDLST) and discharge to hospice (DH) in traumatic brain injury (TBI). However, a paucity of data exists in identifying factors associated with end-of-life (EoL) care in younger patients with TBI. We sought to identify hospital and patient factors associated with EoL care and timing of EoL care in younger adults with severe TBI.

Methods: This is a retrospective analysis of the National Trauma Databank (2019). Adults (18-65 y) with severe TBI (Glasgow coma scale <9) were included in the analysis. Inclusion criteria included death, WDLST, or DH during the hospital stay. Exclusion criteria included Glasgow coma scale >8, death in the emergency department, and missing WDLST status. The primary outcome was EoL Care defined as those who either underwent WDLST or DH. The secondary outcome was early EoL care defined as EoL care within 72 h of admission.

Results: A total of 1239 patients were included in the study, the median age was 43 y, and the majority were males (77%) and of white race (68%). A total of 667 (54%) patients underwent EoL Care. On multivariable analysis, increasing age (adjusted odd's ratio [aOR]: 1.02; 95% confidence interval [CI]: 1.01-1.03) and chronic alcoholism (aOR: 1.78; 95% CI: 1.05-3.03) were independently associated with EoL. Conversely, patients of Black race (aOR: 0.33; 95% CI: 0.22-0.49) and those admitted to university hospitals (odd's ratio 0.51 95% CI 0.33-0.74) and level II trauma centers (odd's ratio 0.57; 95% CI 0.37-0.88) were less likely to undergo EoL care. A total of 225 (34%) patients underwent early EoL Care. On multivariable analysis, presence of nonreactive pupils and absence of intracranial pressure monitor were independently associated with early EoL care.

Conclusions: Significant variation in EoL care exists in patients presenting with severe TBI. Better understanding of patient and hospital factors that influence these complex decisions may allow for targeted interventions to reduce variability in EoL practice in TBI across institutions.