Predictors of withdrawal of life-sustaining therapies in older adults with TBI and a modified frailty index score

John J. Francis; Ahmed I. Kashkoush; Vanessa P. Ho; Mary J. Roach; Michael L. Kelly; Mira Ghneim; Jennifer S. Albrecht; Karen Brasel; Anna Livaris; Jill B. Watras; Christopher P. Michetti; James M. Haan; Kelly Lightwine; Robert D. Winfield; Sasha D. Adams; Jeanette M. Podbielski; Scott B. Armen; J.Christopher Zacko; Fady S. Nasrallah; Kathryn B. Schaffer; Julie Dunn; Lars Widdel; Thomas J. Schroeppel; Zachery Stillman; Zara Cooper; Deborah Stein; Charles Adams; Stephanie Lueckel; Jason Murry; Nikita Patel; Cindy Hsu; Umer F. Bhatti; Matthew E. Lissauer; Marc LaFonte; Kaveh Najafi; Karen Lewandowski; Kaushik Mukherjee; Kristelle E. Imperio-Lagabon; Niels D. Martin; Kathleen Hirsch; Cherisse Berry; Derek Freitas; Daniel Cullinane; Roshini Ramawi; Michael Truitt; Chris Pearcy; Habiba Hashimi; Krista Kaups; Jeffry Claridge; Husayn Ladhani; Jennifer L. Hartwell; Jessica Ballou; Martin Croce; Stephanie Markle; Sally Osserwaarde; Joseph Posluszny; Benjamin Stocker; Tjasa Hranjec; Rachele Solomon; Lucy Martinek; Alok Gupta; Daniel J. Grabo; Uzer Khan; Danielle Tatum; Tomas Jacome; Jonathan Gates; Alisha Jawani; Allison E. Berndtson; Terry G. Curry; Miklosh Bala; Linda A. Dultz; Natasha N. Houshmand; Paola Pieri; Martin D Zielinski; Joy D. Hughes; Jennifer Hartwell; Ajai K. Malhotra; Tim Lee; Patrizio Petrone; D’andrea Joseph; Gary T. Marshall; Matthew M. Carrick; Abhijit Pathak; Andrea Van Zandt; Nina Glass; David Livingston; Shea Gregg; Travis Webb; Byron Drumheller; Rosemary Kozar; Robert Barraco; Bellal Joseph; the American Association for the Surgery of Trauma GERI-TBI Study Group

doi:10.1016/j.jocn.2025.111191

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Predictors of withdrawal of life-sustaining therapies in older adults with TBI and a modified frailty index score

Journal article

Peer reviewed

Predictors of withdrawal of life-sustaining therapies in older adults with TBI and a modified frailty index score

John J. Francis, Ahmed I. Kashkoush, Vanessa P. Ho, Mary J. Roach, Michael L. Kelly, Mira Ghneim, Jennifer S. Albrecht, Karen Brasel, Anna Livaris, Jill B. Watras, …

Journal of clinical neuroscience, Vol.135, p.111191

05/01/2025

DOI: https://doi.org/10.1016/j.jocn.2025.111191

PMID: 40107005

Abstract

Frailty

Traumatic brain injury

Withdrawal of life-sustaining therapies

•Age, GCS, surgery, and DNR status were all independently associated with withdrawal of life-sustaining therapies for patients with TBI.•Pre-injury frailty was not associated with withdrawal of life-sustaining therapies.•Our findings may help guide management of traumatic brain injury in older adults. Withdrawal-of-life-sustaining-therapies (WLST) in patients with traumatic brain injury (TBI) is a complex decision-making process. The clinical factors related to WLST in older adults with TBI are currently poorly understood. The present study aims to determine the clinical predictors of WLST in older patients with TBI. All patients ≥ 65 years old with TBI (Head Abbreviated Injury Scale Score ≥ 3) were identified from the Geriatric TBI Database, a prospective registry of patients admitted to 45 trauma centers nationwide with TBI between 2017–2019. We collected factors related to past medical history, baseline demographic data, clinical presentation, TBI sub-type, neurosurgical interventions, and do-not-attempt-resuscitation (DNAR) orders. The primary outcome measure was WLST. Binary logistic regression was subsequently performed to determine factors independently associated with WLST. A total of 1600 patients were identified. The median age was 80 years old and 48.6 % of patients were male. In this cohort, 120 patients (7.5 %) underwent WLST. A logistic regression model revealed that Glasgow Coma Scale (GCS) (OR 0.82; 95 %-CI 0.77––0.87), cerebral edema (3.2; 1.5–7.0), craniotomy/craniectomy (2.5; 1.4–4.4), and DNAR (8.8; 5.5–14.3) were all independently associated with WLST. This model demonstrated excellent discrimination ability with a concordance statistic of 0.935. This study demonstrates that patients ≥ 65 years old with poor initial GCS, cerebral edema, craniotomy/craniectomy, and DNAR were all independently associated with WLST. Pre-injury frailty was not associated with WLST. Further studies are needed to evaluate the prognostic value of frailty indices in the management of patients with TBI.

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Title: Predictors of withdrawal of life-sustaining therapies in older adults with TBI and a modified frailty index score
Creators: John J. Francis - Case Western Reserve University
Ahmed I. Kashkoush - Cleveland Clinic
Vanessa P. Ho - MetroHealth Medical Center
Mary J. Roach - MetroHealth Medical Center
Michael L. Kelly - MetroHealth Medical Center
Mira Ghneim - University of Maryland Medical Center
Jennifer S. Albrecht - University of Maryland School of Medicine
Karen Brasel - Jackson Memorial Hospital
Anna Livaris - University of Maryland Medical Center
Jill B. Watras - Inova Design Solutions
Christopher P. Michetti - Inova Design Solutions
James M. Haan - Ascension Via Christi Hospital
Kelly Lightwine - Ascension Via Christi Hospital
Robert D. Winfield - University of Kansas Medical Center
Sasha D. Adams - The University of Texas Health Science Center at Houston
Jeanette M. Podbielski - The University of Texas Health Science Center at Houston
Scott B. Armen - Pennsylvania State University
J.Christopher Zacko - Pennsylvania State University
Fady S. Nasrallah - Scripps Memorial Hospital
Kathryn B. Schaffer - Scripps Memorial Hospital
Julie Dunn - Medical Center of the Rockies, 2500 Rocky Mountain Ave, Loveland, CO 80538, USA
Lars Widdel - Medical Center of the Rockies, 2500 Rocky Mountain Ave, Loveland, CO 80538, USA
Thomas J. Schroeppel - UC Health Memorial Hospital, 1400 E Boulder St, Colorado Springs, CO 80909, USA
Zachery Stillman - UC Health Memorial Hospital, 1400 E Boulder St, Colorado Springs, CO 80909, USA
Zara Cooper - Brigham and Women's Hospital
Deborah Stein - Univeristy of California San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, USA
Charles Adams - Rhode Island Hospital
Stephanie Lueckel - Rhode Island Hospital
Jason Murry - The University of Texas Health Science Center at Tyler
Nikita Patel - The University of Texas Health Science Center at Tyler
Cindy Hsu - University of Michigan
Umer F. Bhatti - University of Michigan
Matthew E. Lissauer - Rutgers-Robert Wood Johnson Medical School, Clinical Academic Building (CAB), 125 Paterson St, New Brunswick, NJ 08901, USA
Marc LaFonte - Rutgers-Robert Wood Johnson Medical School, Clinical Academic Building (CAB), 125 Paterson St, New Brunswick, NJ 08901, USA
Kaveh Najafi - Honor Health Scottdale Osborn Medical Center, 7400 E Osborn Rd, Scottsdale, AZ 85251, USA
Karen Lewandowski - Honor Health Scottdale Osborn Medical Center, 7400 E Osborn Rd, Scottsdale, AZ 85251, USA
Kaushik Mukherjee - Loma Linda University Medical Center
Kristelle E. Imperio-Lagabon - Loma Linda University Medical Center
Niels D. Martin - University of Pennsylvania
Kathleen Hirsch - University of Pennsylvania
Cherisse Berry - New York University/Bellevue Hospital Center, 462 1st Avenue, New York, NY 10016, USA
Derek Freitas - New York University/Bellevue Hospital Center, 462 1st Avenue, New York, NY 10016, USA
Daniel Cullinane - Marshfield Clinic
Roshini Ramawi - Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449, USA
Michael Truitt - Methodist Dallas Medical Center
Chris Pearcy - Methodist Dallas Medical Center
Habiba Hashimi - University of California, San Francisco
Krista Kaups - University of California, San Francisco
Jeffry Claridge - MetroHealth Medical Center
Husayn Ladhani - MetroHealth Medical Center
Jennifer L. Hartwell - Indiana University Health
Jessica Ballou - Jackson Memorial Hospital
Martin Croce - University of Tennessee Health Science Center
Stephanie Markle - Ascension
Sally Osserwaarde - Ascension
Joseph Posluszny - Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
Benjamin Stocker - Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA
Tjasa Hranjec - Memorial Regional Hospital, 1150 N 35th Ave Suite 600, Hollywood, FL 33021, USA
Rachele Solomon - Memorial Regional Hospital, 1150 N 35th Ave Suite 600, Hollywood, FL 33021, USA
Lucy Martinek - Beth Israel Deaconess Medical Center
Alok Gupta - Beth Israel Deaconess Medical Center
Daniel J. Grabo - West Virginia University
Uzer Khan - West Virginia University
Danielle Tatum - Our Lady of the Lake Regional Medical Center
Tomas Jacome - Our Lady of the Lake Regional Medical Center
Jonathan Gates - Hartford Hospital
Alisha Jawani - Hartford Hospital
Allison E. Berndtson - University of California San Diego Medical Center
Terry G. Curry - University of California San Diego Medical Center
Miklosh Bala - Hadassah Hebrew University Medical Center, Sderot Churchill 8, Jerusalem, Israel
Linda A. Dultz - The University of Texas Southwestern Medical Center
Natasha N. Houshmand - The University of Texas Southwestern Medical Center
Paola Pieri - Theodore Roosevelt High School
Martin D Zielinski - Mayo Clinic
Joy D. Hughes - Mayo Clinic
Jennifer Hartwell - Indiana University
Ajai K. Malhotra - University of Vermont
Tim Lee - University of Vermont
Patrizio Petrone - New York University Winthrop Hospital, 259 1st St, Mineola, NY 11501, USA
D’andrea Joseph - New York University Winthrop Hospital, 259 1st St, Mineola, NY 11501, USA
Gary T. Marshall - Medical Center of Plano, 3901 W 15th St, Plano, TX 75075, USA
Matthew M. Carrick - Medical Center of Plano, 3901 W 15th St, Plano, TX 75075, USA
Abhijit Pathak - Temple University Hospital
Andrea Van Zandt - Temple University Hospital
Nina Glass - Rutgers Medical School University Hospital, 150 Bergen St, Newark, NJ 07103, USA
David Livingston - Rutgers Medical School University Hospital, 150 Bergen St, Newark, NJ 07103, USA
Shea Gregg - Bridgeport Hospital
Travis Webb - Medical College of Wisconsin
Byron Drumheller - University of Maryland Medical Center
Rosemary Kozar - University of Maryland Medical Center
Robert Barraco - University of Arizona
Bellal Joseph - University of San Francisco
the American Association for the Surgery of Trauma GERI-TBI Study Group
Publication Details: Journal of clinical neuroscience, Vol.135, p.111191
Publisher: Elsevier Ltd
Identifiers: 991006228433802656
Academic Unit: College of Nursing; Surgery
Language: English
Resource Type: Journal article

Predictors of withdrawal of life-sustaining therapies in older adults with TBI and a modified frailty index score

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