In-hospital end-of-life decisions after new traumatic spinal cord injury in the Netherlands.

STUDY DESIGN: Explorative retrospective files study. OBJECTIVES: To document end-of-life decisions (ELDs) in in-hospital deaths after new traumatic spinal cord injury (TSCI). SETTING: The Netherlands. METHODS: Discharge letters concerning patients with TSCI discharged from Dutch acute hospitals in 2010 were analysed. Data were extracted on survival, personal and lesion characteristics, comorbidities, other injuries, preexisting spinal stenosis, stabilising surgery, length of hospital stay and the presence and types of ELDs. Characteristics of deceased patients and survivors were compared using χ2 and T-tests. Characteristics of the deceased patients and ELDs were further explored. RESULTS: A total of 185 patients with new TSCI were identified. Twenty-six patients were excluded as their survival status at discharge was unknown-for example, because of discharge to another hospital without information about their final discharge. Thirty of the remaining 159 patients died during their initial hospital stay (18.9%). Deceased patients were older and had more often high cervical and motor complete injuries than survivors. The circumstances of death were sparsely documented, and in nine cases, it was not possible to determine the absence or the presence of an ELD. ELDs were reported in 19 deaths (63.3%). All were non-treatment decisions, and almost all (89.5%) were decisions of withdrawal of treatment. There were no cases of documented euthanasia or physician-assisted suicide. CONCLUSION: ELDs were reported in the majority of in-hospital deaths after new TSCI in the Netherlands (63.3%), and all were non-treatment decisions.

Causes of death following spinal cord injury during inpatient rehabilitation and the first five years after discharge. A Dutch cohort study.

STUDY DESIGN: Prospective multicentre cohort study. OBJECTIVES: To determine mortality, causes and determinants of death of individuals with spinal cord injury (SCI) within five years after first inpatient rehabilitation. SETTING: The Netherlands. METHODS: Patients were included on admission to first clinical rehabilitation after traumatic or nontraumatic SCI. INCLUSION CRITERIA: age between 18 and 65, American Spinal Injury Association impairment scale A-D and expected long-term wheelchair dependency. Information about survival, cause of death, relevant comorbidity and psychosocial circumstances was obtained from the rehabilitation physician or general practitioner. Determinants of death were retrieved from a prospectively collected database. Deceased persons and survivors were compared using χ(2)-test and t-test. Cox regression analysis was performed to describe independent predictors of death. The Kaplan-Meier method was used to calculate survival curves for independent predictors. Excess mortality was described by a standardized mortality ratio (SMR). RESULTS: Mean duration of follow up was 6.2 years. A total of 27 persons (12.2%) died during this period (SMR 5.3). Main causes of death were cardiovascular disease (37.0%), pulmonary disease (29.6%) and neoplasm (14.8%). Older age at injury, nontraumatic SCI, family history of cardiovascular disease, less social support and a history of other medical conditions on admission were related to death. Older age at injury, nontraumatic SCI and a history of other medical conditions were independent predictors of death. CONCLUSION: Twelve per cent of persons with SCI who had survived the acute hospital phase died during follow up (SMR 5.3). The main causes of death were cardiovascular and pulmonary disease.

Characteristics, length of stay and functional outcome of patients with spinal cord injury in Dutch and Flemish rehabilitation centres.

STUDY DESIGN: Multi-centre prospective descriptive study. OBJECTIVE: To establish a profile of the population affected with traumatic and non-traumatic spinal cord injury (SCI) admitted to rehabilitation centres in the Netherlands and Flanders (Belgium) and to describe determinants of length of stay (LOS) and functional outcome. SETTING: Eleven rehabilitation centres in the Netherlands and Flanders. PATIENTS: A total of 919 patients with traumatic and non-traumatic SCI on first admission to rehabilitation centres between 2002 and 2007. METHODS: Information about LOS, functional outcome and personal and injury characteristics was derived from a joint data set developed for this project. RESULTS: A total of 54.7% of patients with SCI had a non-traumatic lesion. The group of patients with non-traumatic SCI showed a more even gender distribution, a more advanced age and less severe lesion characteristics than the group of patients with traumatic SCI. Linear regression models explained 32% of the variance of LOS and 42% of the variance of functional outcome. Functional status on admission was the strongest determinant of LOS and completeness of the lesion was the strongest determinant of functional outcome. Aetiology (traumatic versus non-traumatic) was a weak independent determinant of LOS but was not an independent determinant of functional outcome. CONCLUSION: Patients with non-traumatic SCI formed a majority in the Dutch and Flemish SCI population. Although the characteristics of patients with traumatic and non-traumatic SCI clearly differed, rehabilitation of patients with non-traumatic SCI appears at least as efficient as rehabilitation of patients with traumatic SCI.