The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment

Abstract

Background: There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients.

Methods: This retrospective analysis of the American College of Surgeons- Trauma Quality Improvement Program (2017-2019) included all severely injured (Injury Severity Score >15) geriatric trauma patients (≥65 years). Multivariable logistic regression was performed to identify independent predictors of WLST.

Results: There were 155,583 patients included. Mean age was 77 ± 7 years, 55% were male, 97% sustained blunt injury, and the median Injury Severity Score was 17 [16-25]. Overall WLST rate was 10.8%. On MLR analysis, increasing age (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.33-1.37; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.09-1.18; p < 0.001), White race (aOR, 1.44; 95% CI, 1.36-1.52; p < 0.001), frailty (aOR, 1.42; 95% CI, 1.34-1.50; p < 0.001), government insurance (aOR, 1.27; 95% CI, 1.20-1.33; p < 0.001), presence of advance directive limiting care (aOR, 2.55; 95% CI, 2.40-2.70; p < 0.001), severe traumatic brain injury (aOR, 1.80; 95% CI, 1.66-1.95; p < 0.001), ventilator requirement (aOR, 12.73; 95% CI, 12.09-13.39; p < 0.001), and treatment at higher level trauma centers (Level I aOR, 1.49; 95% CI, 1.42-1.57; p < 0.001; Level II aOR, 1.43; 95% CI, 1.35-1.51; p < 0.001) were independently associated with higher odds of WLST.

Conclusion: Our results suggest that nearly one in 10 severely injured geriatric trauma patients undergo WLST. Multiple patient and hospital related factors contribute to decision making and directed efforts are necessary to create a more standardized process.

Level of evidence: Prognostic and Epidemiological; Level III.