Trauma Service, Scripps Mercy Hospital, San Diego, California 92103, USA.
J Trauma Acute Care Surg. 2012 May;72(5):1186-93. doi: 10.1097/TA.0b013e31824d0e57.
Withdrawal or limitation of care (WLC) in trauma patients has not been well studied. We reviewed 10 years of deaths at our adult Level I trauma center to identify the patients undergoing WLC and to describe the process of trauma surgeon-managed WLC.
This is a retrospective review of WLC. Each patient was assigned to one of three modes of WLC: care withdrawn, limited or no resuscitation, or organ harvest. Frequency, timing, and circumstances of WLC, including family involvement, ethics committee consultation, palliative care, and hospice, were reviewed.
From 2000 through 2009, 375 patients died with WLC (54% of all deaths; 93% at ≥ 24 hours). For age ≥ 65 years, 80% were WLC. Overall, 15% had advance directive documents. Traumatic brain or high cervical spine injury was the cause of death in 63%. Factors associated with WLC included age, comorbidities, injury mechanism and severity, and nontrauma activation status. At time of death, 316 (84%) WLC were under trauma surgeon management. In this group, mode of WLC was care withdrawn in 74%, organ harvest in 20%, and limited or no resuscitation in 6%. Rationale for WLC in non-organ harvest patients was poor neurologic prognosis in 86% and futility in 76%. When family was identified, end-of-life discussions with physicians occurred in 100%. Conflicts over WLC occurred in 6.6% and were not associated with any demographic group. Ethics committee was involved in 2.8%. For care-withdrawn patients, median time to death from first WLC order was 6.6 hours. Palliative care and hospice consults (6% and 9%) increased yearly.
WLC occurred in over 50% of all trauma deaths and exceeded 90% at ≥ 24 hours. Hospice and palliative care were increasingly important adjuncts to WLC. Guidelines for WLC should be developed to ensure quality end-of-life care for trauma patients in whom further care is futile.
III, therapeutic study.
创伤患者的治疗终止或限制（WLC）尚未得到充分研究。我们回顾了我院成人 I 级创伤中心 10 年的死亡病例，以确定接受 WLC 的患者，并描述创伤外科医生管理的 WLC 过程。
这是一项 WLC 的回顾性研究。每位患者被分配到 WLC 的三种模式之一：停止治疗、限制或不进行复苏，或进行器官捐献。回顾了 WLC 的频率、时间和情况，包括家属参与、伦理委员会咨询、姑息治疗和临终关怀。
2000 年至 2009 年，375 例患者在接受 WLC 后死亡（占所有死亡病例的 54%；93%的死亡发生在≥24 小时后）。≥65 岁的患者中，80%接受了 WLC。总体而言，15%的患者有预先指示文件。创伤性脑损伤或高位颈椎损伤是导致 63%死亡的原因。与 WLC 相关的因素包括年龄、合并症、损伤机制和严重程度以及非创伤激活状态。在死亡时，316 例（84%）WLC 由创伤外科医生管理。在这一组中，74%的患者停止了治疗，20%的患者进行了器官捐献，6%的患者进行了限制或不进行复苏。非器官捐献患者进行 WLC 的理由是 86%的患者神经预后不良和 76%的患者治疗无效。当家属被识别时，100%的医生与家属进行了临终讨论。6.6%的患者发生了 WLC 冲突，但与任何人群无关。伦理委员会参与了 2.8%的病例。对于停止治疗的患者，从第一次 WLC 医嘱下达到死亡的中位时间为 6.6 小时。姑息治疗和临终关怀咨询（分别为 6%和 9%）逐年增加。
超过 50%的创伤死亡患者接受了 WLC，≥24 小时后这一比例超过 90%。临终关怀和姑息治疗是 WLC 的重要辅助手段。应制定 WLC 指南，以确保对进一步治疗无效的创伤患者提供高质量的临终关怀。
III 级，治疗性研究。
