In my previous post, I reviewed a recent paper analyzing which geriatric patients were more likely to have care withdrawn after serious injury.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• Patients with an activity-limiting injury were 3x more likely to have care withdrawn (7.5% vs 2.5%)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.

Traumatic injury is a continuum ranging from very minor to immediately fatal. The mortality rate along that continuum rises exponentially as the Injury Severity Score (ISS) increases. We long ago moved away from the philosophy of keeping someone alive at all costs to embracing the concept of quality of life. We have become more thoughtful about considering patient and family input in difficult cases.

This occurs more frequently when we treat geriatric patients. The mortality for a given ISS increases even more steeply than in younger patients and continues to accelerate for each decade of life. It is becoming routine to have goals of care discussions with patients and their families in most areas of medicine. Although commonplace in specialties like oncology, it is not as common in trauma care.

Withdrawal of life support is one of the endpoints of these goals of care discussions. However, making such a decision with the patient and/or family is challenging. Too soon, and there may be missed opportunities for recovery. Too late, and the patient and family may be further traumatized by futile or undesired care.

Is it possible to identify the common factors that predict appropriate withdrawal of care? The University of Arizona at Tucson group analyzed the Trauma Quality Improvement Program (TQIP) database on withdrawal of care from 2017-2019. The authors included only patients aged 65 and older. They sought to identify the predictors of care withdrawal. They also calculated their frailty index to gauge its impact on withdrawal decision-making.

Here are the factoids:

• Over 150K patients were included in the analysis, with a mean age of 77 and predominantly blunt mechanism (97%)
• About 19% were judged to be frail by applying an 11-variable frailty index
• About 1 in 10 had withdrawal of support
• Factors that increased the likelihood of support withdrawal were increasing age (1.4x more likely), frailty (1.4x), impaired activities of daily living (ADLs) (2.6x), and ventilator requirement (13x)
• There was no difference between Level I and Level II trauma centers
• Only 9% of patients had an advance directive
• Interestingly, 19% of patients who had support withdrawn did not die

Bottom line: The authors only attempted to describe what factors were more likely to be present in patients who underwent withdrawal of care. A simple TQIP database analysis does not contain the data necessary to reliably develop suggested criteria. However, this study is very valuable because it offers a possible basic framework.

Age, frailty, ADLs, and vent dependence were the major variables noted. This alone may make the trauma professional more confident in approaching the family in cases where there is no advance directive. Which, unfortunately, is the majority of patients. 

But more importantly, we really need to define when the most appropriate time for the withdrawal discussion to occur. It requires a careful balance between potentially stopping too soon and persisting into futility.

In my next post, I’ll review another paper on this topic, using TQIP data, also published earlier this year. I’ll compare and contrast the results and see if we can get a clearer picture of how to proceed in the challenging cases.

Reference: The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life-supporting treatment. J Trauma Acute Care Surg. 2023 Jun 1;94(6):778-783.