Factors associated with death and limitation of life-sustaining therapies in patients with traumatic brain injury

Abstract

Aim of the Study: A substantial proportion of deaths of patients in the Intensive Care Unit (ICU) follow a decision to limit life-sustaining therapies. Patients with moderate to severe Traumatic Brain Injury (TBI) differ from the general ICU population: They are usually younger, previously healthy, and often with no advance directives. The objective of this study was to identify factors associated with mortality and limitation of life-sustaining therapies in patients with moderate to severe traumatic brain injury in a Swiss academic tertiary care hospital. Methods: This study was a retrospective single center analysis of 170 non-elective admissions to the surgical ICU of a Swiss academic tertiary care hospital over a three-year period. Patients were eligible for the study if diagnosed with moderate to severe blunt TBI, and if the ICU length of stay was at least 48 hrs. Factors associated with mortality were investigated. Results: Mean age was 48 ± 21 years, 72.3% were male, and pre-existing medical conditions were overall rare. Forty-five patients (26.5%) died within 6 months after TBI (Non-survivors group). Most deaths (n=43, 95.5%) occurred after limitation of life-sustaining therapies. In the multiple binary logistic regression model age, Protestant religion, hypoxemia during the rescue phase, a higher category in the Marshall classification and a higher Injury Severity Score were independently associated with death. Conclusion: At our institution, most deaths of patients with moderate to severe TBI occurred after a deliberate decision to limit life-sustaining therapies. This decision was associated with age, spiritual belief of the patient, hypoxemia in the pre-hospital setting, radiological findings, and severity scores. Written advance directives should be encouraged to help surrogate decision makers and physicians in the acute and sudden setting of TBI to respect the patient’s willed.