• Alexis F Turgeon, François Lauzier, Jean-François Simard, Damon C Scales, Karen E A Burns, Lynne Moore, David A Zygun, Francis Bernard, Maureen O Meade, Tran Cong Dung, Mohana Ratnapalan, Stephanie Todd, John Harlock, Dean A Fergusson, and Canadian Critical Care Trials Group.
• Centre de Recherche du Centre hospitalier affilié universitaire de Québec-Hôpital de l'Enfant-Jésus, Traumatologie-Urgence-Soins Intensifs, Université Laval, Québec, Que. alexis.turgeon@fmed.ulaval.ca
• CMAJ. 2011 Oct 4;183(14):1581-8.

BackgroundSevere traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine.MethodsTo evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale).ResultsWe randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%-35.2%) and ranged from 10.8% to 44.2% across centres (χ(2) test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%-75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ(2) test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care.InterpretationWe observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.

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