Withdrawal of life-sustaining treatment in patients with moderate to severe traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of death and injury worldwide, and it accounts for nearly one-third of deaths among severely injured trauma patients. Some individuals who sustain a severe TBI experience unresponsive wakefulness syndrome (UWS), a condition in which injury-related functional impairment is so great that the individual lapses into a vegetative state. Because people in vegetative states do not demonstrate signs of consciousness, they may require permanent medical intervention for survival. In cases where recovery is unlikely, loved ones may choose to withdraw life-sustaining treatment. Although research currently exists on end-of-life practices for patients with TBI, few studies have investigated the relationship between withdrawal of treatment, TBI severity, and survivor outcomes. Not much is currently known about quality of life for those who do eventually recover from UWS.

To address this gap in research, a group of researchers studied hospital data from 179 adults who were admitted to a Dutch hospital with moderate to severe TBI over a four-year period. The researchers gathered data about the patients’ injuries, their experience with withdrawal of treatment, and their survival rates. They found that:

  • Older individuals and those with more severe TBI were more likely to undergo withdrawal of life-sustaining treatment.
  • For 40% of patients, loved ones made the decision to withdraw life-sustaining treatment on the same day as admission.
  • Of the 33% of patients who did not survive their injuries, the vast majority died after life-sustaining treatment was withdrawn.
  • Almost three-quarters of patients who recovered from their vegetative state reported good functional outcomes within three months of leaving the hospital. No patient relapsed into UWS after three months post-injury.

The decision to withdraw life-sustaining treatment is a serious consideration for loved ones of individuals who have sustained a severe TBI. Although UWS is not always permanent, a return individuals may experience functional and neurological impairments that can significantly reduce quality of life. However, this research suggests that for some individuals, functional outcomes can improve in the post-UWS recovery period, and survival rates are optimistic. The researchers note that the decision to withdraw life-sustaining treatment is culturally specific, and they urge other researchers to explore end-of-life practices outside of the Netherlands.

Jochems D, van Wessem KJP, Houwert, RM, et al. Outcome in patients with isolated moderate to severe traumatic brain injury. Critical Care Research and Practice. (September 2018).

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