End-of-Life Decision-Making for Patients With Geriatric Trauma Cared for in a Trauma Intensive Care Unit

Abstract

Background:

The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives.

Materials and Methods:

We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC.

Results:

A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC (P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS (P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order (P = .93).

Conclusions:

Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient’s wishes via living wills or advanced directives “in a terminal condition” and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.

Keywords

geriatric trauma end of life critical care palliative care advanced directives

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References

Centers for Disease Control and Prevention. Older adult falls: Get the facts. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Updated February 10, 2017. Accessed December 2, 2016.

DeLa’O

Kashuk

Rodriguez

Zipf

Dumire

. The geriatric trauma institute: reducing the increasing burden of trauma care. Am J Surg. 2014;208(6):988–94.

Moore

Turgeon

Sirois

. Trauma centre outcome performance: a comparison of young adults and geriatric patients in an inclusive trauma system. Injury. 2012;43(9):1580–1585.

Carpenter

Rosen

. Trauma in the geriatric patient. In: Mattu

Grossman

Rosen

, eds. Geriatric Emergencies: A Discussion-Based Review. Chichester, UK: John Wiley & Sons Inc; 2016:280–303.

Oreskovich

Howard

Copass

Carrico

. Geriatric trauma: injury patterns and outcome. J Trauma. 1984;24(7):565–572.

Perdue

Watts

Kaufmann

Trask

. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma. 1998;45(4):805–810.

Osler

Hales

Baack

. Trauma in the elderly. Am J Surg. 1988;156(6):537–543.

Finelli

Jonsson

Champion

Morelli

Fouty

. A case control study for major trauma in geriatric patients. J Trauma. 1989;29(5):541–548.

Broos

D’Hoore

Vanderschot

Rommens

Stappaerts

. Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury. 1993;24(6):365–368.

10.

Morris

Jr MacKenzie

Damiano

Bass

. Mortality in trauma patients: the interaction between host factors and severity. J Trauma. 1990;30(12):1476–1482.

11.

Morris

JAJ

MacKenzie

Edelstein

. The effect of preexisting conditions on mortality in trauma patients. JAMA. 1990;263(14):1942–1946.

12.

Milzman

Boulanger

Rodriguez

Soderstrom

Mitchell

Magnant

. Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score. J Trauma. 1992;32(14):236–243.

13.

Knudson

Lieberman

Morris

Jr Cushing

Stubbs

. Mortality factors in geriatric blunt trauma patients. Arch Surg. 1994;129(4):448–453.

14.

Rozzelle

Wofford

Branch

. Predictors of hospital mortality in older patients with subdural hematoma. J Am Geriatr Soc. 1995;43(3):240–244.

15.

Kilaru

Garb

Emhoff

. Long-term functional status and mortality of elderly patients with severe closed head injuries. J Trauma. 1996;41(6):957–963.

16.

Bonne

Schuerer

. Trauma in the older adult: epidemiology and evolving geriatric principles. Clin Geriatr Med. 2013;29(1):137–150.

17.

Ayoung-Chee

McIntyre

Ebel

Mack

McCormick

Maier

. Long-term outcomes of ground level falls in the elderly. J Trauma. 2014;76(2):498–503.

18.

National Comprehensive Cancer Network. Practice guidelines in oncology. Palliative Care. www.nccn.org/professionals/physicians_gls/PDP/palliative.pdf. Updated December 19, 2017. Accessed May 16, 2017.

19.

National Institute on Aging. End of Life: Helping with Comfort and Care. U.S. Department of Health and Human Services. 2016. https://www.nia.nih.gov/health/publication/end-life-helping-comfort-and-care/planning-end-life-care-decisions. Accessed May 16, 2017.

20.

Kale

Ornstein

Smith

. End-of-life discussions with older adults. J Am Geriatr Soc. 2016;64(10):1962–1967. doi:10.1111/jgs.14285.

21.

Martin

Stefanelli

Methvin

. Contrasting patient, family, provider, and societal goals at the end of the life complicate decision making and induce variability of care after trauma. J Trauma Acute Care Surg. 2014;77(2):62–267.

22.

American College of Surgeons Trauma Quality Improvement Guidelines for Geriatric Trauma. https://www.facs.org/∼/media/files/quality%20programs/trauma/tqip/geriatric%20guide%20tqip.ashx. Accessed March 23, 2016.

23.

Joseph

Jokar

Hassan

. Redefining the association between old age and poor outcomes after trauma: the impact of frailty syndrome. J Trauma. 2017;82(30):575–581. DOI: 10.1097/TA.0000000000001329

24.

Brown

Rix

Klein

. A comprehensive investigation of comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. Am Surg. 2016;82(11):1055–1062.

25.

Baldwin

Sell

Heyden

. Race, ethnicity, health insurance, and mortality in older survivors of critical illness. Crit Care Med. 2017;45(6):583–591. doi:10.1097/CCM.0000000000002313.

26.

Lenworth

Burns

Bennett Jacobs

. Trauma death views of the public and trauma professionals on death and dying from injuries. Arch Surg. 2008;143(8):730–735.

27.

Sanders

Chow

Enzinger

. Seeking and accepting: U.S. Clergy theological and moral perspectives informing decision making at the end of life. J Palliat Med. 2017;20(10):1059–1067. doi:10.1089/jpm.2016.0545.

28.

Mosenthal

Murphy

Barker

Lavery

Retano

Livingston

. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;64(6):1587–1593. doi:10.1097/TA.0b013e318174f112.

29.

O’Mahony

McHenry

Blank

. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010;24(2):154–165. doi:10.1177/0269216309346540.