Management of the geriatric trauma patient at risk of death - Therapy withdrawal decision making

Hypothesis: The management of geriatric injured patients admitted to a trau ma center includes the selective decision to provide comfort care only, inc luding withdrawal of therapy, and a choice to not use full application of s tandard therapies. The decision makers in this process include multiple ind ividuals in addition to the patient. Design: Retrospective review of documentation by 2 blinded reviewers of the cohort of patients over a recent 5-year period (1993-1997). Setting: Trauma service of a level I trauma center. Patients: A convenience sample of patients aged 65 years and older who died , and whose medical record was available for review. Main Outcome Measures: Patients were categorized as hating withdrawal of th erapy, and documentation in the medical record of who made the assessment d ecisions and recommendations, and to what extent the processes of care were documented. Results: Among 87 geriatric trauma patients who died, 47 had documentation interpreted as indicating a decision was made to withdraw therapy. In only a few circumstances was the patient capable of actively participating in th ese decisions. The other individuals involved in recommendations for withdr aw nl of therapy were, in order of prevalence, the treating trauma surgeon, family members (as proxy reporting the patient's preferences), ora second physician. Documentation regarding the end-of-life decisions was often frag mentary, and in some cases ambiguous. Copies of legal advance directives we re rarely available in the medical record, and ethics committee participati on was used only once. Conclusions: Withdrawal of therapy is a common event in the terminal care o f geriatric injured patients. The process for reaching a decision regarding withdrawal of therapy is complex because in most circumstances patients' i njuries preclude their full participation. Standards for documentation of e ssential information, including patients' preferences and decision-making a bility, should be developed to improve the process and assist with recordin g these complicated decisions that often occur over several days of discuss ion.