Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

Abstract

Background: In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods:The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression.Results: A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3-12.4) or two unreactive pupils (OR 5.8, CI 2.6-13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0-1.1). Timing of WLSM was not significantly associated with region or center. Conclusion:WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis.

Prognostic Models for Traumatic Brain Injury Have Good Discrimination but Poor Overall Model Performance for Predicting Mortality and Unfavorable Outcomes

“…15,16 A Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study found that over half of the patients with TBI admitted to the intensive care unit had withdrawal of lifesustaining measures within 72 hours of injury. 17,18 Furthermore, there is a concern that physicians may engage in a "self-fulfilling prophecy" by deciding to withdraw care based on poor prognosis from a model such as CRASH or IMPACT, 15,19,20 resulting in the patient's death. The prognostic model would therefore have confirmed itself without giving the patient a chance at survival, especially when care is withdrawn in the acute stage of injury.…”

The leap to ordinal: Detailed functional prognosis after traumatic brain injury with a flexible modelling approach

“…However, inclusion of these variables may result in problematic self-fulfilling prophecies [ 51 ]. For instance, a physician’s poor prognosis directly influences WLSM, which was instituted in 144 (70.2%) of the 205 patients who died in the ICU [ 52 ]. Including a variable for physician prognosis may then negatively bias the outcome prediction and unduly promote WLSM.…”

The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study

“…This finding is consistent with previous reports in Europe and America. 2 , 4 , 5 , 6 , 7 , 8 , 10 , 11 , 12 …”