Citation

Hornor MA, Byrne JP, Engelhardt KE, Nathens AB. J. Trauma Acute Care Surg. 2018; 84(4): 590-597.

Affiliation

Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.

Copyright

(Copyright © 2018, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000001775

PMID

29261591

Abstract

INTRODUCTION: Racial disparities in medical treatment for seriously injured patients across the spectrum of care are well established, but racial disparities in end of life decision-making practices have not been well described. When time from admission to time to withdrawal of life-sustaining treatment (WLST) increases, so does the potential for ineffective care, healthcare resource loss, and patient and family suffering. We sought to determine the existence and extent of racial disparities in late WLST after severe injury.

METHODS: We queried the American College of Surgeons' (ACS) Trauma Quality Improvement Program (TQIP) (2013 - 2016) for all severely injured patients (injury severity score > 15, age > 16) with a WLST order > 24 hours after admission. We defined late WLST as care withdrawn at a time interval beyond the 75th percentile for the entire cohort. Univariate and multivariate analyses were performed utilizing descriptive statistics, and t-tests and chi-squared tests where appropriate. Multivariable regression analysis was performed with random effects to account for institutional-level clustering using late WLST as the primary outcome, and race as the primary predictor of interest.

RESULTS: 13,054 patients from 393 centers were included in the analysis. Median time to WLST was 5.4 days (IQR 2.6-10.3). In our unadjusted analysis, African-American patients (10.1% vs 7.1%, p<0.001) and Hispanic patients (7.8% vs 6.8%, p<0.001) were more likely to have late WLST as compared to early WLST. After adjustment for patient, injury, and institutional characteristics, African-American (OR 1.42, 95% CI 1.21-1.67) and Hispanic (1.23, 1.04-1.46) race were significant predictors of late WLST.

CONCLUSION: African-American and Hispanic race are both significant predictors of late WLST. These findings might be due to patient preference or medical decision making, but speak to the value in assuring a high standard related to identifying goals of care in a culturally sensitive manner. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Language: en