The impact of country and culture on end-of-life care for injured patients: results from an international survey.

BACKGROUND: Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures. METHODS: A clinician-based, 38-question international survey was used to characterize the impacts of medical, religious, social, and system factors on end-of-life care after trauma. RESULTS: A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%), and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0-27%). The practice structure of American respondents also varied from other regions. Formal medical futility laws are rarely available (14-38%). Ethical consultation services are often accessible (29-98%), but rarely used (0-29%), and typically unhelpful (<30%). End-of-life decision making for patients with traumatic brain injuries varied extensively across regions with regard to the impact of patient age, Glasgow Coma Scale score, and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of "donation after cardiac death" also varied substantially between countries. CONCLUSIONS: In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).

Ten years of major equestrian injury: are we addressing functional outcomes?

BACKGROUND: Horseback riding is considered more dangerous than motorcycle riding, skiing, automobile racing, football and rugby. The integral role of rehabilitation therapy in the recovery of patients who have sustained a major horse-related injury is previously not described. The goals of this paper were to (1) define the incidence and pattern of severe equestrian trauma, (2) identify the current level of in-patient rehabilitation services, (3) describe functional outcomes for patients, and (4) discuss methods for increasing rehabilitation therapy in this unique population. METHODS AND RESULTS: A retrospective review of the trauma registry at a level 1 center (1995-2005) was completed in conjunction with a patient survey outlining formal in-hospital therapy. Forty-nine percent of patients underwent in-patient rehabilitation therapy. Injuries predictive of receiving therapy included musculoskeletal and spinal cord trauma. Previous injury while horseback riding was predictive of not receiving therapy. The majority (55%) of respondents had chronic physical difficulties following their accident. CONCLUSION: Rehabilitation therapy is significantly underutilized following severe equestrian trauma. Increased therapy services should target patients with brain, neck and skull injuries. Improvements in the initial provision, and follow-up of rehabilitation therapy could enhance functional outcomes in the treatment resistant Western equestrian population.

Equestrian injuries: incidence, injury patterns, and risk factors for 10 years of major traumatic injuries.

BACKGROUND: Horseback riding is more dangerous than motorcycle riding, skiing, football, and rugby. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with severe equestrian trauma. METHODS: All patients with major equestrian injuries (injury severity score > or = 12) admitted between 1995 and 2005 were reviewed. A 46-question survey outlining potential rider, animal, and environmental risk factors was administered. RESULTS: Among 7941 trauma patients, 151 (2%) were injured on horseback (mean injury severity score, 20; mortality rate, 7%). Injuries included the chest (54%), head (48%), abdomen (22%), and extremities (17%). Forty-five percent required surgery. Survey results (55%) indicated that riders and horses were well trained, with a 47% recidivism rate. Only 9% of patients wore helmets, however, 64% believed the accident was preventable. CONCLUSIONS: Chest trauma previously has been underappreciated. This injury pattern may be a result of significant rider experience. Helmet and vest use will be targeted in future injury prevention strategies.