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

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 We defined late WLST as care withdrawn at a time interval beyond the 75th percentile for the entire cohort.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 χ 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.