Management of the geriatric trauma patient at risk of death: therapy withdrawal decision making.

HYPOTHESIS: The management of geriatric injured patients admitted to a trauma center includes the selective decision to provide comfort care only, including withdrawal of therapy, and a choice to not use full application of standard therapies. The decision makers in this process include multiple individuals in addition to the patient. DESIGN: Retrospective review of documentation by 2 blinded reviewers of the cohort of patients over a recent 5-year period (1993-1997). SETTING: Trauma service of a level I trauma center. PATIENTS: A convenience sample of patients aged 65 years and older who died, and whose medical record was available for review. MAIN OUTCOME MEASURES: Patients were categorized as having withdrawal of therapy, and documentation in the medical record of who made the assessment decisions and recommendations, and to what extent the processes of care were documented. RESULTS: Among 87 geriatric trauma patients who died, 47 had documentation interpreted as indicating a decision was made to withdraw therapy. In only a few circumstances was the patient capable of actively participating in these decisions. The other individuals involved in recommendations for withdrawal of therapy were, in order of prevalence, the treating trauma surgeon, family members (as proxy reporting the patient's preferences), or a second physician. Documentation regarding the end-of-life decisions was often fragmentary, and in some cases ambiguous. Copies of legal advance directives were rarely available in the medical record, and ethics committee participation was used only once. CONCLUSIONS: Withdrawal of therapy is a common event in the terminal care of geriatric injured patients. The process for reaching a decision regarding withdrawal of therapy is complex because in most circumstances patients' injuries preclude their full participation. Standards for documentation of essential information, including patients' preferences and decision-making ability, should be developed to improve the process and assist with recording these complicated decisions that often occur over several days of discussion.

Survival among injured geriatric patients during construction of a statewide trauma system.

BACKGROUND: Patient outcomes are presumed to vary during early implementation of a trauma system because of fluctuations in processes of care. This study estimates risk-adjusted survival for injured geriatric patients during implementation of the Washington State trauma system. METHODS: A presystem (1988-1992) versus early construction phase (1993-1995) retrospective cohort analysis of hospitalized geriatric injured patients in Washington State was conducted. Hospital data were cross-linked to death certificates, providing patient follow-up. A Cox proportional hazards model assessed survival to 60 days from hospital admission. RESULTS: A total of 77,136 geriatric patients were assessed. No difference in survival was observed (before vs. after) for all geriatric injured patients. However, among severely injured patients (Injury Severity Score > 15), survival during the implementation phase increased by 5.1% compared with patients admitted during the presystem years (p = 0.03). CONCLUSION: This study demonstrates improved survival for seriously injured geriatric trauma patients during construction of the Washington State trauma system.