The Decision To Stop In Geriatric Trauma – Part 2

In my previous post, I reviewed a recent paper analyzing which geriatric patients were more likely to have care withdrawn after serious injury. The authors noted that those with significant limitations to daily living activities, increasing age and/or frailty, and ventilator dependence were major factors.

Today’s paper was written by a multi-institutional group from several Ohio trauma centers. Like the previous paper, the authors used TQIP data for two of the same three years. Patients were at least 65, and deaths within the first 24 hours were excluded. The authors focused on patient groups with and without injuries that limited activities of daily living, so it dovetails with and further refines the conclusions of the previous paper.

Nearly 600,000 patients were identified, with about 550,000 without and 50,000 patients with injuries limiting activities of daily living. The study used propensity matching to examine 39,138 patients with and without these injuries.

Here are the factoids:

  • Patients with an activity-limiting injury were 3x more likely to have care withdrawn (7.5% vs 2.5%)
  • Several additional factors were discovered that were even more predictive of withdrawal of care:
    • Severe injury (ISS > 25) – 23x more likely
    • Unplanned admission to an ICU – 3.3x more likely
    • In-hospital cardiac arrest – 5x

The authors concluded that even if your patient does not have injuries that might limit their daily activities, it is still important to discuss goals of care with our elderly trauma patients.

Bottom line: These two papers, taken together, are saying the same thing. Injured geriatric patients have a higher mortality than similarly injured younger people. Certain factors are associated with ultimate withdrawal of care, including injuries that limit activities of daily living, increasing age and frailty, and unexpected serious events in the hospital, like cardiac arrest and admission to the ICU.

The point is that injuries limiting daily activities are a predictable factor for withdrawal of care. But this is only a small factor. Other unpredictable events, like cardiac arrest or an issue severe enough to require unexpected ICU admission, may be even more predictive. But unless we have a discussion with the patient and their family well in advance, the opportunity will be missed and may result in unwanted and futile care.

Reference: Are we waiting for the sky to fall? Predictors of withdrawal of
life-sustaining support in older trauma patients: A retrospective analysis. J Trauma 94(3):385-391, 2023.

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