The Impact of Preinjury Advanced Directives Among Critically Ill Trauma Patients With Disseminated Cancer Undergoing Withdrawal of Care.

INTRODUCTION

Advanced directives (ADs) clarify patients' end-of-life preferences while preventing escalations of care against their wishes. This is especially important for critically ill trauma patients, who may be unable to communicate their preferences. National Comprehensive Cancer Network guidelines recommend all patients with disseminated cancer should discuss ADs after diagnosis. However, the impact of ADs in trauma patients with disseminated cancer who undergo withdrawal of life-sustaining treatment remains unclear. This study aimed to evaluate this relationship, hypothesizing patients with a preinjury AD to have shorter hospital and intensive care unit (ICU) length of stay before withdrawal of life-sustaining treatment compared to those without ADs.

METHODS

The 2017-2023 Trauma Quality Improvement Program database was queried for trauma patients with preinjury disseminated cancer who were admitted to the ICU and underwent withdrawal of life-sustaining treatment. Patients were stratified by the presence or absence of a preinjury AD. Bivariate analyses compared demographics, injury profiles, and outcomes between the two cohorts.

RESULTS

Of the 2221 patients with known disseminated cancer who had withdrawal of life-sustaining treatment, 414 (18.6%) had a preinjury AD. Patients with ADs were older (77 versus 74, P < 0.001), and more often insured by Medicare (72.6% versus 65.8%, P = 0.003). Preinjury functional dependence (27.2% versus 22.1%; P = 0.028) was more common in the AD cohort, whereas rates of other comorbidities were similar between cohorts. Mechanism of injury, admission vitals, and Injury Severity Score were also comparable between groups (all P > 0.05). Patients with a preinjury AD had decreased hospital (5 versus 6 d, P = 0.035) and ICU length of stay (3 versus 4 d, P = 0.003) compared to those without an AD.

CONCLUSIONS

In this national analysis spanning 6 y of data, less than one-fifth of trauma patients with disseminated cancer had a preinjury AD. However, an AD was associated with decreased time to withdrawal of life-sustaining treatment, underscoring the importance of conducting these discussions following cancer diagnosis.