Are We Waiting for the Sky to Fall? Predictors of Withdrawl of Life-Sustaining Support in Older Trauma Patients: A Retrospective Analysis
Limited data exist regarding the impact of advanced care planning for injured geriatric patients. We hypothesized that patients with advance directives limiting care (ADLC) compared to those without ADLC are more likely to undergo withdrawal of life-sustaining support (WLSS).
This is a propensity-matched analysis utilizing American College of Surgeons Trauma Quality Improvement Program (ACSTQIP) patients ≥65 years who presented between 2017-2018. Patients with and without ADLC on admission were compared. The primary outcome was WLSS and days prior to WLSS.
Additional factors examined included hospital length of stay (LOS), unplanned operations, unplanned intensive care unit (ICU) admissions, and in-hospital cardiac arrests.
Prior to matching, logistic regression model assessed factors associated with WLSS. Patients with and without ADLC were matched 1:1 via a propensity score using patient and injury factors as covariates, and matched pair analysis compared differences in WLSS between patients with and without ADLC.
597,840 patients were included: 44,001 patients with an ADLC (7.36%) compared to 553,839 with no ADLC (92.64%). Patients with an ADLC underwent WLSS more often than those with no ADLC (7.68% vs 2.48%, p < 0.001). In a 1:1 propensity matched analysis, patients with ADLC were more likely to undergo WLSS (OR 2.38, 95% CI 2.22-2.55), although stronger predictors of WLSS included severity of injury (ISS 25+ OR 23.84, 95% CI 21.55-26.36), unplanned ICU admissions (OR 3.30, 2.89-3.75), and in-hospital cardiac arrests (OR 4.97, 95%CI 4.02-6.15).
A small proportion of the geriatric trauma population had ADLC on admission. While ADLC was predictive of WLSS, adverse events were more strongly associated with WLSS. To ensure patient-centered care and reduce futile interventions, surgeons should delineate goals of care early regardless of ADLC.