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Examining racial disparities in the time to withdrawal of life-sustaining treatment in trauma

Hornor, Melissa A. MD; Byrne, James P. MD; Engelhardt, Kathryn E. MD; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: April 2018 - Volume 84 - Issue 4 - p 590–597
doi: 10.1097/TA.0000000000001775
AAST 2017 Podium Paper

BACKGROUND 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, health care 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’ Trauma Quality Improvement Program (2013–2016) for all severely injured patients (Injury Severity Score, > 15; age, > 16 years) with a WLST order longer than 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 We defined late WLST as care withdrawn at a time interval beyond the 75th percentile for the entire cohort.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 using descriptive statistics, and t tests and χ2 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 A total of 13,054 patients from 393 centers were included in the analysis. Median time to WLST was 5.4 days (interquartile range, 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 (odds ratio, 1.42; 95% confidence interval, 1.21–1.67) and Hispanic (odds ratio, 1.23; 95% confidence interval, 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.

From the Division of Research and Optimal Patient Care (M.A.H., A.B.N.), American College of Surgeons, Chicago, Illinois; Department of Surgery (M.A.H.), The Ohio State University College of Medicine, Columbus, Ohio; Sunnybrook Research Institute (J.P.B., A.B.N.), Sunnybrook Health Sciences Center; Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation (J.P.B., A.B.N.), Division of General Surgery (J.P.B., A.B.N.), University of Toronto, Toronto, Ontario, Canada; Surgical Outcomes and Quality Improvement Center (K.E.E.), Northwestern University, Evanston, Illinois; and Department of Surgery (K.E.E.), Medical University of South Carolina, Charleston, South Carolina.

Submitted: September 2, 2017, Revised: November 22, 2017, Accepted: November 24, 2017, Published online: December 20, 2017.

Meeting Presentation Information: 76th Annual Meeting of American Association for the Surgery of Trauma, September 13 to 16, 2017, in Baltimore, Maryland.

Address for reprints: Melissa A Hornor, MD, American College of Surgeons, Chicago, IL; email:

© 2018 Lippincott Williams & Wilkins, Inc.