Treatment-limiting decisions made in nearly 50% of severe traumatic brain injury cases

Key takeaways:

• The percentage of treatment-limiting decisions, the majority of which were withholding of therapy, increased over time.
• Just over half of all TLDs were made within 3 days of hospital admission.

Treatment-limiting decisions were made for almost half of patients with severe traumatic brain injuries, with higher rates in those older in age, according to data.

“Although poorly studied, variation in treatment decisions and treatment limitations are likely explained by a physician’s personal and clinical experience, religious background, cultural values and valuation of predicted outcome,” Inge A.M. van Erp, MS, a doctoral student at Leiden University Medical Center in the Netherlands, and colleagues wrote in Brain and Spine.

Van Erp and colleagues investigated the prevalence, timing and considerations of treatment-limiting decisions (TLDs) in those who have suffered severe traumatic brain injuries (s-TBI).

Their retrospective cohort study examined data from 270 individuals with s-TBI and a Glasgow Coma Scale score between 3 and 8 who were treated between 2008 and 2017 at two level one trauma centers in the Netherlands. TLDs were divided into two categories: those who withheld life-saving measures and those where life-sustaining measures were forsaken. Those two categories were subdivided into specific categories regarding ICU admission and neurosurgical intervention, along with escalation of various methods of treatment, withdrawal of or withholding of such.

Baseline characteristics as well as in-hospital outcomes were compared between s-TBI cases with and without TLDs.

According to results, TLDs were reported in 117 of 270 (43.3%) patients with s-TBI. About 96% of deaths following s-TBI were preceded by a TLD. Those with TLD were older compared with those without (58 years vs. 45 years). The percentage of TLDs in patients with s-TBI increased from 20% in 2008 to 42.9% in 2012 and 64.3% in 2017.

The researchers also reported that the majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ support was the highest subcategory (64.1%), while withholding of neurosurgical intervention was recorded in 29.9% of cases.

Data further showed that the median time from admission to TLD was 2 days, with just over half of TLDs made within 3 days of admission. The main reason cited for a TLD was perception of unsalvageability (66.7%). Additionally, almost all TLDs (99.1%) were made by multidisciplinary medical teams, including those made with input from proxies (75.2%).

“The prevalence of TLDs increased over years, independent from prognostic variables,” van Erp and colleagues noted. “TLD should be prospectively investigated and included in clinical trials for better interpretation of studies on therapeutic interventions or prognosis.”