Adding Infectious Insult to Traumatic Injury in End-of-Life Discussions

Elizabeth Tindal; Charles Adams, Jr.; Eric Benoit; Michael Connolly; Daithi Heffernan; Andrew Stephen; Stephanie Lueckel

Traumatic injuries place patients at increased risk of infection but it is not known how this affects goals-of-care decision making. We sought to determine if infectious complications impact the transition to comfort measures only (CMO).

We hypothesized that development of an infection would decrease the time to withdrawal of care (WOC).

A retrospective review from a level one trauma center from April 2015 to June 2017. We included all adult patients (age ≥ 18) who were made CMO, had a length of stay over 1 day and did not have a pre-existing advance directive. Charts were reviewed for patient demographics, injury patterns and hospital course including assessing for occurrences of any infections. Patients were divided into two groups – those who developed an infection and those who did not. Subgroup analysis was done comparing those patients who developed a single infection and those who developed multiple infections. The primary endpoint was time to death or discharge (TTD).

Among the 232 patients who transitioned to CMO, 72 (31%) developed an infection prior to WOC. Pneumonia was the most common infection (24.2%), followed by urinary tract infections (UTI) (8.2%). Those in the infection group had a significantly longer TTD (19.3 vs 3.8 days, p<0.01) despite no significant difference in age (69.9 vs 69.7 years), gender (72.2% vs 65.6% male), injury severity score (ISS) (20.3 vs 22.5), rate of head injury (31.9% vs 24.4%) or rate of dementia (18.1% vs 10.0%). The infection group was further divided into those who developed multiple infections (N=34) versus those who had only a single infection (N=38) prior to WOC. Patients with multiple infections had a significantly longer TTD (26.7 vs 12.7 days, p<0.01) despite no significant difference in age (69 vs 70.6 years), ISS (22.5 vs 18.3), rate of head injury (32.4 vs 31.6%) or rate of dementia (8.8% vs 26.3%).

Our findings do not show that development of an infection will decrease the time to WOC. There is no doubt that a longer length of stay in the hospital increases the risk of developing an infection. However, we believe that the increased TTD in the setting of multiple infections and equivalent patient populations is a marker of a family’s baseline resistance to WOC. Infectious complications play a complicated role in end-of-life discussions for trauma patients.