Withdrawal of Life-Sustaining Therapy in Injured Patients: Variations Between Trauma Centers and Nontrauma Centers

Background: We sought to identify patient and institutional variables predictive of a withdrawal of care order (WOCO) in trauma patients. We hypothesized that the frequency of WOCO would be higher at trauma centers. Methods: Data from the National Study on the Costs and Outcomes of Trauma were used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. chi(2), t tests, and multivariate analysis were used to identify variables predictive of WOCO. Results: Of 14,190 patients, 618 (4.4%) had WOCO, which accounted for 60.9% of patients who died in hospital. Age (p = <0.001), race (p = <0.001), comorbidity (p = <0.001), and injury mechanism were associated with WOCO (p = 0.03). WOCO patients had higher New Injury Severity Score (p = <0.001), lower Glasgow Coma Scale motor scores (p = <0.001), and higher incidence of midline shift on head computed tomography (p = 11.01). Trauma center status (odds ratio, 1.56; 95% confidence interval, 1.06-2.30) and closed intensive care units (odds ratio, 1.53; 95% confidence interval, 1.03-2.25) were also predictive of a WOCO. There was a sizable variation (0%-16%) in the percentage of patients with WOCO across centers. Conclusion: Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed intensive care units are predictive of a WOCO, variation in the percentage of patients with WOCO across all centers speaks to the complexity of these decisions. Further investigation is needed to understand how a WOCO is applied to trauma patients.