A new investigation in CMAJ (Canadian Medical Association Journal) discovered that death after severe traumatic brain injury is linked with a highly variable incidence of withdrawal of life support at the end of life. The rates at which life support is withdrawn varies greatly from hospital-to-hospital. The authors say that when making the decision to withdraw support, careful attention must be used.

Traumatic brain injury is the main cause of death and disability among patients under 45 years of age. Most of the time these patients are not able to make decisions regarding their medical care, so when the decision arises to withdraw life support, their physicians and family members make the choice usually based on poor prognosis, physician experience, the patient’s wishes and/or religious views. Yet, not enough tools exist to accurately predict disability and long-term outcomes for these patients.

Death rates after withdrawal of life support in individuals who had severe traumatic brain injury were examined by a multicenter team of Canadian investigators in six trauma centers in Quebec, Ontario and Alberta. 720 patients over the age of 16 were analyzed, 77 of whom were male. The main cause of injury came from motor vehicle accidents (57%) ,falls (31%) and assault (8%).

The number of deaths varied substantially. 32% (228) out of the 720 patients died in hospital, even though the death rates varied across centers from 11% to 44%. 70% of deaths (ranging from 64% to 76%) were connected with life-support being withdrawn, with approximately half of these deaths occurring within three days.

Dr. Alexis Turgeon, Laval University, Quebec, wrote:

“We saw that most deaths after severe traumatic brain injury occurred after withdrawal of life-sustaining therapy and that the rate of withdrawal of life-sustaining therapy varied significantly across level-one trauma centers.

We also saw considerable variability in overall hospital mortality that persisted after risk adjustment. This raises the concern that differences in mortality between centers may be partly due to variation in physicians’ perceptions of long-term prognosis and physicians’ practice patterns for recommending withdrawal of life-sustaining therapy.

Until accurate diagnostic tools are available, careful attention must be used in both estimating prognoses for those with severe traumatic brain injury and in recommending the withdrawal of life-support.”

In an additional report, Drs.David Livingston and Anne Mosenthal, Department of Surgery, New Jersey Medical School write:

“Although we attribute the variability in withdrawal of life-sustaining therapy to differences in patient preferences, the article by Turgeon and colleagues adds to the growing body of literature that physician practice and the culture of medical centers may play an equally strong role.”

Differences in how physicians control prognostic uncertainty in severe traumatic brain injury and the way they communicate this uncertainty to families and patients is another reason for the large discrepancy in treatments between trauma centers, according to Dr. Livingston and Dr. Mosenthal.

Written by Grace Rattue