Ri Chia-Po Fu/VS Huang

1. Who had life-sustaining therapy withdrawn after injury The journal of TRAUMA injury, infection and critical care December 2005 Ri Chia-Po Fu/VS Huang

2. Background (1) • Trauma, the 5th leading cause of deaths in adults>65 y/o • ↑ age→ Mortality↑ after injury • MICU and SICU differences • Traumatic patients do not have ability to communicate their wishes as to how aggressive their care should be.

3. Background (2) • How to make accurate prognoses regarding the risk of death, disability due to severe injury? • It’s difficult→ trauma scoring systems→ to help determine patient’s survival probabilities. • No scoring systems take into account whether life-sustaining therapy was DC. • It’s also difficult to predict whether an individualized patient will live or die purely based on physiologic, injury severity, and age

4. Background (3) • Scoring systems are difficult to use • Patients respond to insults differentially • Physicians differ • Convey inaccurate risks of death • Physician risk stratification affects palliative or aggressive therapy

5. Purpose of the study • Examine factors associated with withdrawal of life-sustaining therapy (WLST) • Its hypothesis: patients with --advanced age, --comorbid medical illness --increased injury severity --complications during hospitalization --preinjury advance directives • would be likely to have undergone WLST→ palliative care

6. Patients and methods • Patients>55 y/o→ injury→ admitted in ICU→ died in hospital • Medical record reviews to identify factors associated WLST

7. Results (1) • 330 patients, 20% died (n=66) • 64/66 patients have complete records • Family discussion: 50/64 (78.1%), no patients participated • Average time of 1st family discussion: 4.6 days (0~32 days) • 53/64 had DNR, average time 0.78 days • 25/53 died on the same day • 21/53 did not undergo WLST

10. Result (2) • Factors associated with/without family discussion, not age, injury severity, specific brain or chest injury, and comorbidities, but advance directives and higher TRISS • Timing of first discussion did not correlate with patient age, ISS, head AIS, chest AIS, or number of comorbidities

12. Result (3) • Only presence of family discussion was significantly associated with WLST • WLST was associated with higher opioid and BZD usage on the immediate predeath day.

14. Discussion (1) • The Patient Self-Determination Act (PSDA) assumes: each person has a fundamental right to control his own body • PSDA’s purpose: to encourage patients to decide early about the types and extent of medical care in case they become unable to make decisions

15. Discussion (2) • Primary care physician and geriatricians v.s. emergency and trauma surgeons --more opportunity to address end-of-life issues and advance directives • If injured patient are awake on arrival →discuss advance directives • Trunkey et al: --specific variables including age, ISS, pre-existing comorbidities, and GSC on admission did not predict WLST --Family discussion predicted withdraw of care • Plaisier et al: age was not a factor in therapy withdraw, despite a higher frequency of comorbid medical illness

16. Discussion (3) • 4 principles provide the framework for WLST --Establish the source of authority for decision making --Achieve effective communication with patient and family --Make an early determination and ongoing review of the patient’s desire --Recognize the patient’s rights

17. Discussion (4) • In contrast to trauma population, WLST was well studied in MICU • WLST↑ in last decade • 1990, Smedira et al: 5% patients in MICU underwent WLST • Brain death and poor prognosis were the primary indication • Contributing factors: futility of tx, extreme suffering, patient or surrogate request

18. Discussion (5) • We assumed: the practice of WLST was driven by advanced age, injury severity, comorbid medical illness, and complication. • It was wrong and corroborate Trunkey and Plaisier’s findings.

19. Conclusion • In the patients who underwent WLST, the dosage of administered analgesics and sedatives was higher. • No significant associations between age, comorbid medical illness, ISS, or complications and WLST • Documented family discussion clearly shows an association with WLST

20. Thank you!!