{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:06:09Z","timestamp":1787875569944,"version":"build-2784847793"},"reference-count":36,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"unspecified","delay-in-days":15,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2026,6,12]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Trauma-specific palliative care guidelines are limited, and physicians rely heavily on experience to guide goals-of-care discussions, leading to substantial practice variation. Existing literature does not adequately account for the marked heterogeneity among trauma patients. How traumatic brain injury influences the timing and determinants of delayed withdrawal of life-sustaining treatment in patients with concomitant major extracranial injuries remains poorly understood.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective cohort study of patients \u226516 years with withdrawal of life-sustaining treatment in the American College of Surgeons Trauma Quality Improvement Program database (2021\u20132023). Patients were stratified by the presence of moderate to severe traumatic brain injury. The primary outcome was time to withdrawal of life-sustaining treatment. Our secondary aim was to assess predictors of delayed withdrawal (&gt;75th percentile for each group) using separate binary logistic regression models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 41\u2009990 patients, 23\u2009101 (55%) had a moderate to severe traumatic brain injury. Withdrawal occurred earlier in patients with moderate to severe traumatic brain injury (median 4\u2009days (IQR 2\u20139)\u2009vs. 6\u2009days (3\u201312), p&lt;0.0001). The probability of delayed withdrawal increased non-linearly with increasing complication burden, plateauing near 100% after seven complications, with the first four having the greatest marginal effect. In patients with moderate to severe traumatic brain injury, unique predictors of delayed withdrawal included diffuse axonal injury, decompressive surgery, and intracranial pressure monitoring. The only major extracranial injury with predictive value was major chest injury (OR 1.3, 95%\u2009CI 1.1 to 1.4, p&lt;0.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Withdrawal of life-sustaining treatment occurs earlier in patients with moderate to severe traumatic brain injury and appears to be driven by distinct factors. Complications may serve as practical triggers for goals-of-care discussions. In polytrauma patients with moderate to severe traumatic brain injury, withdrawal decisions appear to be predominantly influenced by factors related to neurological injury. These findings support pursuing a more nuanced approach to palliative care research in the trauma intensive care unit.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of evidence<\/jats:title>\n                    <jats:p>Level III.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/tsaco-2026-002251","type":"journal-article","created":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T15:25:31Z","timestamp":1784215531000},"page":"e002251","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Patterns in withdrawal of life-sustaining treatment in trauma patients with and without moderate to severe traumatic brain injury: an ACS-TQIP retrospective cohort study"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2571-7406","authenticated-orcid":false,"given":"Nicole","family":"Russell","sequence":"first","affiliation":[{"name":"Surgery, University of Rochester Medicine, Rochester, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander L","family":"Eastman","sequence":"additional","affiliation":[{"name":"Trauma Services, Medical Center of Plano, Plano, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer L","family":"Grant","sequence":"additional","affiliation":[{"name":"Texas Christian University Anne Burnett Marion School of Medicine, Fort Worth, Texas, USA"},{"name":"Surgery, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,16]]},"reference":[{"key":"2026071608251863000_11.3.e002251.1","unstructured":"Committee on Trauma, American College of Surgeons . TQIP PUF Version A.Y. Chicago, IL,"},{"key":"2026071608251863000_11.3.e002251.2","doi-asserted-by":"crossref","DOI":"10.1186\/s13049-019-0648-9","article-title":"Neurocritical care physicians\u2019 doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study","volume":"27","author":"Robertsen","year":"2019","journal-title":"Scand J Trauma Resusc Emerg Med"},{"key":"2026071608251863000_11.3.e002251.3","doi-asserted-by":"crossref","first-page":"2336","DOI":"10.1089\/neu.2024.0014","article-title":"Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis","volume":"41","author":"Sanders","year":"2024","journal-title":"J Neurotrauma"},{"key":"2026071608251863000_11.3.e002251.4","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2025.1714","article-title":"Recovery Potential in Patients After Cardiac Arrest Who Die After Limitations or Withdrawal of Life Support","volume":"8","author":"Elmer","year":"2025","journal-title":"JAMA Netw Open"},{"key":"2026071608251863000_11.3.e002251.5","unstructured":"American College of Surgeons Trauma Quality Improvement Program . ACS TQIP palliative care best practice guidelines. 2017. Available: https:\/\/www.facs.org\/media\/g3rfegcn\/palliative_guidelines.pdf [Accessed 24 May 2025]."},{"key":"2026071608251863000_11.3.e002251.6","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1097\/TA.0000000000004151","article-title":"Would you be surprised? Prospective multicenter study of the Surprise Question as a screening tool to predict mortality in trauma patients","volume":"96","author":"Hoffman","year":"2024","journal-title":"J Trauma Acute Care Surg"},{"key":"2026071608251863000_11.3.e002251.7","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2702.2008.02465.x"},{"key":"2026071608251863000_11.3.e002251.8","doi-asserted-by":"crossref","first-page":"944","DOI":"10.1089\/jpm.2019.0478","article-title":"Impact of Advance Directives on Outcomes and Charges in Elderly Trauma Patients","volume":"23","author":"Hill","year":"2020","journal-title":"J Palliat Med"},{"key":"2026071608251863000_11.3.e002251.9","doi-asserted-by":"crossref","first-page":"1055","DOI":"10.1177\/000313481608201119","article-title":"A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients","volume":"82","author":"Brown","year":"2016","journal-title":"Am Surg"},{"key":"2026071608251863000_11.3.e002251.10","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1097\/TA.0000000000003400","article-title":"The patient\u2019s voice matters: The impact of advance directives on elderly trauma patients","volume":"92","author":"Lee","year":"2022","journal-title":"J Trauma Acute Care Surg"},{"key":"2026071608251863000_11.3.e002251.11","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1177\/00031348211011115","article-title":"Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma","volume":"89","author":"Haines","year":"2023","journal-title":"Am Surg"},{"key":"2026071608251863000_11.3.e002251.12","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.jcrc.2020.04.001","article-title":"End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study","volume":"58","author":"van Veen","year":"2020","journal-title":"J Crit Care"},{"key":"2026071608251863000_11.3.e002251.13","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.190154"},{"key":"2026071608251863000_11.3.e002251.14","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.jss.2024.10.046","article-title":"Predictors of End-of-Life Care in Nonelderly Adults With Severe Traumatic Brain Injury","volume":"304","author":"Tentis","year":"2024","journal-title":"J Surg Res"},{"key":"2026071608251863000_11.3.e002251.15","doi-asserted-by":"crossref","first-page":"950","DOI":"10.1016\/j.chest.2023.12.028","article-title":"Hospital Policy Variation in Addressing Decisions to Withhold and Withdraw Life-Sustaining Treatment","volume":"165","author":"Piscitello","year":"2024","journal-title":"Chest"},{"key":"2026071608251863000_11.3.e002251.16","doi-asserted-by":"crossref","first-page":"e311","DOI":"10.1016\/j.wneu.2021.12.056","article-title":"Factors Affecting Neurosurgeons\u2019 Decisions to Forgo Life-Sustaining Treatments After Traumatic Brain Injury","volume":"159","author":"Bozkurt","year":"2022","journal-title":"World Neurosurg"},{"key":"2026071608251863000_11.3.e002251.17","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1080\/02699052.2024.2309656","article-title":"Timing of withdrawal of life-sustaining therapy in traumatic brain injury: exploring indicators of poor prognosis in adult and geriatric populations","volume":"38","author":"Bath","year":"2024","journal-title":"Brain Inj"},{"key":"2026071608251863000_11.3.e002251.18","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1016\/j.burns.2010.08.009","article-title":"End of life decisions and care of the adult burn patient","volume":"37","author":"Ismail","year":"2011","journal-title":"Burns"},{"key":"2026071608251863000_11.3.e002251.19","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(14)70030-4"},{"key":"2026071608251863000_11.3.e002251.20","unstructured":"American College of Surgeons Committee on Trauma . National trauma data standard data dictionary. 2022. Available: https:\/\/facs.org\/qualityprograms\/trauma\/ntdb\/ntds\/data-dictionary [Accessed 08 Apr 2025]."},{"key":"2026071608251863000_11.3.e002251.21","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(07)61602-X"},{"key":"2026071608251863000_11.3.e002251.22","doi-asserted-by":"publisher","DOI":"10.1089\/neu.2006.0035"},{"key":"2026071608251863000_11.3.e002251.23","unstructured":"MedCalc . IMPACT score for outcomes in head injury. Available: https:\/\/www.mdcalc.com\/calc\/10014\/impact-score-outcomes-head-injury [Accessed 29 May 2025]."},{"key":"2026071608251863000_11.3.e002251.24","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1016\/S2213-2600(24)00404-1","article-title":"Decisions to withdraw or withhold life-sustaining therapies in patients with and without acute brain injury: a secondary analysis of two prospective cohort studies","volume":"13","author":"Taran","year":"2025","journal-title":"Lancet Respir Med"},{"key":"2026071608251863000_11.3.e002251.25","doi-asserted-by":"crossref","first-page":"811","DOI":"10.1227\/NEU.0b013e318235d640","article-title":"Prognostic value of major extracranial injury in traumatic brain injury: an individual patient data meta-analysis in 39,274 patients","volume":"70","author":"van Leeuwen","year":"2012","journal-title":"Neurosurgery"},{"key":"2026071608251863000_11.3.e002251.26","doi-asserted-by":"publisher","DOI":"10.1016\/s1474-4422(21)00138-1"},{"key":"2026071608251863000_11.3.e002251.27","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1097\/TA.0000000000001852","article-title":"Prognosis of diffuse axonal injury with traumatic brain injury","volume":"85","author":"Humble","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"key":"2026071608251863000_11.3.e002251.28","doi-asserted-by":"publisher","DOI":"10.1016\/j.injury.2017.05.038"},{"key":"2026071608251863000_11.3.e002251.29","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0183552","article-title":"The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator","volume":"12","author":"Letsinger","year":"2017","journal-title":"PLoS One"},{"key":"2026071608251863000_11.3.e002251.30","doi-asserted-by":"crossref","first-page":"884","DOI":"10.1089\/sur.2021.091","article-title":"Adding Infectious Insult to Traumatic Injury: The Impact of Infectious Complications in End-of-Life Decision Making","volume":"22","author":"Tindal","year":"2021","journal-title":"Surg Infect (Larchmt)"},{"key":"2026071608251863000_11.3.e002251.31","doi-asserted-by":"crossref","first-page":"1196","DOI":"10.1001\/jamasurg.2024.2967","article-title":"Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury","volume":"159","author":"Shakil","year":"2024","journal-title":"JAMA Surg"},{"key":"2026071608251863000_11.3.e002251.32","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2024.21711","article-title":"Insurance Type and Withdrawal of Life-Sustaining Therapy in Critically Injured Trauma Patients","volume":"7","author":"Hoit","year":"2024","journal-title":"JAMA Netw Open"},{"key":"2026071608251863000_11.3.e002251.33","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1097\/TA.0000000000001775","article-title":"Examining racial disparities in the time to withdrawal of life-sustaining treatment in trauma","volume":"84","author":"Hornor","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"key":"2026071608251863000_11.3.e002251.34","doi-asserted-by":"crossref","first-page":"998","DOI":"10.1016\/j.amjsurg.2021.08.007","article-title":"Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma","volume":"223","author":"Williams","year":"2022","journal-title":"Am J Surg"},{"key":"2026071608251863000_11.3.e002251.35","doi-asserted-by":"publisher","DOI":"10.1378\/chest.10-3011"},{"key":"2026071608251863000_11.3.e002251.36","doi-asserted-by":"publisher","DOI":"10.1186\/cc3487"}],"container-title":["Trauma Surgery &amp; Acute Care Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/tsaco-2026-002251","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T15:25:35Z","timestamp":1784215535000},"score":1,"resource":{"primary":{"URL":"https:\/\/tsaco.bmj.com\/lookup\/doi\/10.1136\/tsaco-2026-002251"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":36,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,7,16]]},"published-print":{"date-parts":[[2026,7]]}},"alternative-id":["10.1136\/tsaco-2026-002251"],"URL":"https:\/\/doi.org\/10.1136\/tsaco-2026-002251","relation":{},"ISSN":["2397-5776"],"issn-type":[{"value":"2397-5776","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7]]}}}