Sage Journals: Discover world-class research

Abstract

Background

Several studies have described the population of adult trauma patients who undergo withdrawal of life-sustaining treatments (WLST); however, no study has looked specifically at trauma patients who undergo WLST following surgery.

Methods

This was a retrospective chart review of all trauma patients who underwent surgery at our trauma center between January 1 and December 31, 2017. Demographics were collected along with injury patterns and advance directives. Charts of all patients who died or who were discharged to hospice were analyzed to determine whether WLST occurred. Statistics included Fisher’s exact test and Mann-Whitney U test.

Results

Three thousand and twenty-five adult trauma patients received care and 1495 (49.4%) had operations. Thirty (2.0%) patients underwent WLST, 15 (50.0%) of whom died in the hospital and 15 (50.0%) of whom were discharged to hospice. Twenty-six (86.7%) patients had a palliative care consult and 12 (40.0%) had prior advance directives. The most common injuries were femur fractures and subdural hematomas. Adjusting for age, white race, and age-adjusted CCI, femur fracture patients had, on average, 8.8 more hours between presentation and surgery (95% CI 2.1-15.4, P = .01) and 39 fewer hours between surgery and WLST (95% CI −107–29, P = .26) than traumatic brain injury patients.

Discussion

The short time between surgery and WLST in this cohort of patients may demonstrate that surgery was not aligned with patients’ goals of care. A patient-centered approach that includes surgeon-driven palliative care discussions may help avoid nonbeneficial surgery in the last few days of life.

Keywords

trauma palliative care comfort care withdrawal of life sustaining treatment advance directives

Get full access to this article

View all access options for this article.

References

CDC . Underlying cause of death 1999–2017 on CDC WONDER online database. 2018. Accessed January 14, 2020. https://wonder.cdc.gov/controller/datarequest/D76

Bonne

Schuerer

DJE

. Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137-150.doi:10.1016/j.cger.2012.10.008

http://www.ncbi.nlm.nih.gov/pubmed/23177604

Gardner

RC.

Dams-O'Connor

Morrissey

MR.

Manley

. Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions. J Neurotrauma. 2018;35(7):889-906.doi:10.1089/neu.2017.5371

http://www.ncbi.nlm.nih.gov/pubmed/29212411

Burns

Kakara

. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018;67(18):509-514.doi:10.15585/mmwr.mm6718a1

http://www.ncbi.nlm.nih.gov/pubmed/29746456

Mackenzie

Fowler

. Epidemiology. In: Feliciano

Mattox

Moore

, eds. Trauma. 6th ed. McGraw Hill; 2008:Ch. 2.25-2.40.

Leopold

. Editorial: do-not-resuscitate orders and advance directives--existential issues for orthopaedic patients with life-threatening conditions. Clin Orthop Relat Res. 2016;474(4):867-870.doi:10.1007/s11999-015-4687-x

26769617

Côte

Turgeon

AF.

Lauzier

et al. Factors associated with the withdrawal of life-sustaining therapies in patients with severe traumatic brain injury: a multicenter cohort study. Neurocrit Care. 2013;18(1):154-160.doi:10.1007/s12028-012-9787-9

http://www.ncbi.nlm.nih.gov/pubmed/23099846

Leonard

JM.

Polites

SF.

Martin

et al. Comfort care in trauma patients without severe head injury: in-hospital complications as a trigger for goals of care discussions. Injury. 2019;50(5):1064-1067.doi:10.1016/j.injury.2019.01.024

http://www.ncbi.nlm.nih.gov/pubmed/30745124

Quill

TE.

Abernethy

. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.doi:10.1056/NEJMp1215620

http://www.ncbi.nlm.nih.gov/pubmed/23465068

10.

ACS TQIP . Palliative Care Best Practices. 2017. Accessed January 14, 2020 . https://www.facs.org/-/media/files/qualityprograms/trauma/tqip/palliative_guidelines.ashx

11.

Enumah

Lilley

EJ.

Nitzschke

et al. Increased hospice enrollment and decreased neurosurgical interventions without changes in mortality for older medicare patients with moderate to severe traumatic brain injury. Am J Surg. 2018;215(6):1016-1019.doi:10.1016/j.amjsurg.2018.02.028

http://www.ncbi.nlm.nih.gov/pubmed/29534816

12.

Cunningham

HB.

Scielzo

SA.

Nakonezny

et al. Trauma surgeon and palliative care physician attitudes regarding goals-of-care delineation for injured geriatric patients. Am J Hosp Palliat Care. 2019;36(8):669-674.doi:10.1177/1049909118823182

http://www.ncbi.nlm.nih.gov/pubmed/30614253

13.

Simons

AE.

Karres

Nijland

LMG

et al. Do-not-resuscitate orders and early mortality in hip fracture patients. Age Ageing. 2017;46(6):946-951.doi:10.1093/ageing/afx027

http://www.ncbi.nlm.nih.gov/pubmed/28338851

14.

Jawa

RS.

Shapiro

MJ.

McCormack

et al. Preadmission do not resuscitate advanced Directive is associated with adverse outcomes following acute traumatic injury. Am J Surg. 2015;210(5):814-821.doi:10.1016/j.amjsurg.2015.04.007

http://www.ncbi.nlm.nih.gov/pubmed/26116324

15.

American College of Surgeons . Statement on advance directives by patients: “Do not resuscitate” in the operating room. Bull Am Coll Surg. 2014;99:42-43.

Early Comfort Care Following Operative Intervention for Traumatic Injury