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J Trauma. 2009 May;66(5):1327-35. doi: 10.1097/TA.0b013e31819ea047.

Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers.

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  • 1Division of Trauma, Burns, and Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. zcooper@partners.org



We sought to identify patient and institutional variables predictive of a withdrawal of care order (WOCO) in trauma patients. We hypothesized that the frequency of WOCO would be higher at trauma centers.


Data from the National Study on the Costs and Outcomes of Trauma were used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. chi, t tests, and multivariate analysis were used to identify variables predictive of WOCO.


Of 14,190 patients, 618 (4.4%) had WOCO, which accounted for 60.9% of patients who died in hospital. Age (p = <0.001), race (p = <0.001), comorbidity (p = <0.001), and injury mechanism were associated with WOCO (p = 0.03). WOCO patients had higher New Injury Severity Score (p = <0.001), lower Glasgow Coma Scale motor scores (p = <0.001), and higher incidence of midline shift on head computed tomography (p = 0.01). Trauma center status (odds ratio, 1.56; 95% confidence interval, 1.06-2.30) and closed intensive care units (odds ratio, 1.53; 95% confidence interval, 1.03-2.25) were also predictive of a WOCO. There was a sizable variation (0%-16%) in the percentage of patients with WOCO across centers.


Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed intensive care units are predictive of a WOCO, variation in the percentage of patients with WOCO across all centers speaks to the complexity of these decisions. Further investigation is needed to understand how a WOCO is applied to trauma patients.

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