Hospital mortality, withdrawal of life-sustaining therapy decisions and early secondary brain insults for critically ill traumatic brain injury patients in England, Wales and Northern Ireland (2009-2024): an observational cohort study.

Summary

In a 15-year, 235-ICU cohort of 45,684 TBI patients, hospital mortality rose from 25.6% to 35.0% and WLST decisions from 7.5% to 19.7%, trends not seen in comparator cohorts. Exposure to early secondary brain insults, notably hypoxemia, increased substantially. Findings urge re-examination of WLST processes, neuroprotective care quality, and system factors influencing decisions.

Key Findings

• Hospital mortality in ICU TBI patients increased from 25.6% to 35.0% (2009–2024).
• WLST decisions increased from 7.5% to 19.7%, independent after adjustment.
• No similar increases were observed in trauma, sepsis, or vascular brain injury comparator cohorts.
• Exposure to hypoxemia rose from 36.9% to 61.2%; hypotension, (hypo/hyper)capnia, and hyperglycemia were common.

Clinical Implications

Prioritize prevention of secondary brain insults (e.g., hypoxemia) through protocolized neuroprotective bundles and continuous monitoring. Establish transparent, multidisciplinary WLST frameworks with structured prognostication and bias mitigation.

Limitations

• Observational design limits causal inference regarding WLST and mortality
• Potential secular changes in case mix, practice patterns, and documentation

Future Directions

Prospective studies to disentangle prognostication accuracy, decision-making processes, and modifiable care pathways; quality initiatives targeting hypoxemia and physiologic derangements.