Impact of withdrawal of care and futile care on trauma mortality.


BACKGROUND:The observed to expected (O:E) mortality based on Injury Severity Scores (ISS) has been used to assess quality of trauma center (TC) care. Injuries in the elderly have increased, and these patients often have advanced directives, on occasion limiting aggressive care even for potentially survivable injuries; unfortunately, there are few data on the impact of these demographic changes on mortality. Additionally, many patients arrive moribund and care provided is likely to be futile. We sought to examine the impact of these situations on TC mortality. METHODS:All trauma deaths for 2008-2009 were assessed for ISS, preventability of mortality, potential for survivability, impact of withdrawal of care (WOC), and timing of deaths. RESULTS:There were 5433 patients with 347 deaths (6.4%). Deaths occurred more frequently in men (70%) who were older (56.3 years) and had head injuries (70%, Glasgow Coma Scale score of 6.9). The average ISS was high (25.5), but 19% of deaths occurred in minimally injured (ISS < 15). One fifth of all patients who died arrived in or rapidly progressed to cardiac arrest with little to no chance to impact survival. Of the nonsurvivors, 147 (42% of deaths) had WOC at a mean of 1.5 days based on advanced directives (18%) or family desires. Combing WOC and futile care, medical treatment could not have been expected to impact survival in 62% of deaths. CONCLUSION:There has been a major shift in the demographics of the injured with a high proportion of elderly and head injured and/or those who have little likelihood of survival. Crude mortality or O:E based on ISS overestimates preventable deaths. Societal factors, presence of advanced directives, and WOC decisions must be considered when assessing TC performance. Although our crude mortality rate was 6.4%, it was only 2.4% in patients we were actually permitted to treat. We suggest a WOC factor should be added to TC data to characterize mortality rates more accurately.






Franklin GA,Cannon RW,Smith JW,Harbrecht BG,Miller FB,Richardson JD




Has Abstract


2011-10-01 00:00:00
















  • Dextrose containing intravenous fluid impairs outcome and increases death after eight minutes of cardiac arrest and resuscitation in dogs.

    abstract::Use of dextrose in intravenous resuscitation fluids is common practice; however, this study indicates that 5% dextrose solutions, even if administered in physiologic quantities, greatly worsens the outcome of survivable cardiac arrest. Twelve adult male mongrel dogs were premedicated with morphine, anesthetized with h...


    pub_type: 杂志文章


    authors: D'Alecy LG,Lundy EF,Barton KJ,Zelenock GB

    更新日期:1986-09-01 00:00:00

  • Hemostasis in minimally invasive liver surgery.

    abstract::Two cases are reviewed here that highlight the utility of minimally invasive surgery (MIS) techniques in major surgery procedures involving the liver. They also demonstrate specific operative procedures once thought beyond the scope of the MIS surgeon, but they are now standard in expert hands. Improved methods for at...


    pub_type: 杂志文章


    authors: Saxton ML

    更新日期:2007-10-01 00:00:00

  • Acidosis plus melphalan induces nitric oxide-mediated tumor regression in an isolated limb perfusion human melanoma xenograft model.

    abstract:BACKGROUND:Isolated limb perfusion (ILP) with melphalan is an accepted treatment for intransit melanoma of the extremities. Using an ILP human melanoma xenograft model, we tested the hypothesis that acidosis augments the antitumor effect of melphalan and that nitric oxide (NO) induction mediates tumor regression. METH...


    pub_type: 杂志文章


    authors: Kelley ST,Menon C,Buerk DG,Bauer TW,Fraker DL

    更新日期:2002-08-01 00:00:00

  • Dopamine induces neutrophil apoptosis through a dopamine D-1 receptor-independent mechanism.

    abstract:BACKGROUND:For the normal resolution of an acute inflammatory response, neutrophil (PMN) apoptosis is essential to maintain immune homeostasis and to limit inappropriate host tissue damage. A delay in PMN apoptosis has been implicated in the pathogenesis of the systemic inflammatory response syndrome (SIRS). Dopamine, ...


    pub_type: 杂志文章


    authors: Sookhai S,Wang JH,McCourt M,O'Connell D,Redmond HP

    更新日期:1999-08-01 00:00:00

  • Influence of continuous hemofiltration on the hemodynamics of trauma patients.

    abstract:BACKGROUND:The aim of this prospective randomized controlled study was to investigate the effects of continuous venovenous hemofiltration on the hemodynamics and respiratory function of critically ill trauma patients with multiple organ dysfunction syndrome. METHODS:Thirty consecutive critically ill, mechanically vent...


    pub_type: 临床试验,杂志文章,随机对照试验


    authors: Sanchez-Izquierdo Riera JA,Alted E,Lozano MJ,Pérez JL,Ambrós A,Caballero R

    更新日期:1997-11-01 00:00:00

  • Depressed cytotoxic activity of hepatic nonparenchymal cells in rats with obstructive jaundice.

    abstract:BACKGROUND:The nonparenchymal cells (NPC) of the liver have strong cytotoxic activity. Our hypothesis is that their activity may be imparted by obstructive jaundice and show recovery after biliary drainage. METHODS:In Donryu rats, we performed either a sham operation (group C; n = 5), production of irreversible obstru...


    pub_type: 杂志文章


    authors: Hirazawa K,Hazama S,Oka M

    更新日期:1999-11-01 00:00:00

  • Public-private implementation of integrated emergency response services: Case study of GVK Emergency Management and Research Institute in Karnataka, India.

    abstract:BACKGROUND:Emergency medical services are important to the functioning of health systems, but these services tend to be neglected in low- and middle-income countries, such as India. In recent years, several models of pre-hospital emergency medical services have emerged in India. Research on these models holds important...


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    authors: Sriram VM,Gururaj G,Hyder AA

    更新日期:2017-12-01 00:00:00

  • "Taking over somebody's life": Experiences of surrogate decision-makers in the surgical intensive care unit.

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    authors: Lilley EJ,Morris MA,Sadovnikoff N,Luxford JM,Changoor NR,Bystricky A,Bader AM,Cooper Z

    更新日期:2017-08-01 00:00:00

  • Tailored neurectomy for treatment of postherniorrhaphy inguinal neuralgia.

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    pub_type: 杂志文章


    authors: Loos MJ,Scheltinga MR,Roumen RM

    更新日期:2010-02-01 00:00:00

  • Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: which criterion is the most accurate?

    abstract:BACKGROUND:The quick parathyroid hormone assay (QPTH) reliably measures intact parathyroid hormone (iPTH) levels intraoperatively. The accuracy in predicting postoperative calcemia is related to blood sample timing and the criteria applied. To improve specificity or to decrease the cost of QPTH, several criteria have b...


    pub_type: 杂志文章


    authors: Carneiro DM,Solorzano CC,Nader MC,Ramirez M,Irvin GL 3rd

    更新日期:2003-12-01 00:00:00

  • Adrenal surgery for hypercortisolism--surgical aspects.

    abstract:BACKGROUND:Patients with endogenous hypercortisolism are thought to be at high risk for adrenalectomy and may experience significant postoperative surgical mortality/morbidity. METHODS:From 1981 through 1991, 91 patients underwent adrenal resection for endogenous hypercortisolism. Causes were adrenal-dependent Cushing...


    pub_type: 杂志文章


    authors: van Heerden JA,Young WF Jr,Grant CS,Carpenter PC

    更新日期:1995-04-01 00:00:00

  • Clinical implications of portal hemodynamics after small-diameter portacaval H graft.

    abstract::To assess the role of portal hemodynamics in the development of postshunt encephalopathy, we studied 19 patients after small-diameter portacaval H grafting (SD-PCHG). We used contrast studies as well as technetium-labeled macroaggregated albumin injected into the portal vein to assess direction of portal flow. We then...


    pub_type: 杂志文章


    authors: Sarfeh IJ,Rypins EB,Fardi M,Conroy RM,Mason GR,Lyons KP

    更新日期:1984-08-01 00:00:00

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    abstract:BACKGROUND:Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mo...


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    authors: Hechenbleikner EM,Zheng C,Lawrence S,Hong Y,Shara NM,Johnson LB,Al-Refaie WB

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    pub_type: 杂志文章


    authors: Spencer TD,Goldman MH,Hyslop JW,Lee HM,Barnes RW

    更新日期:1984-11-01 00:00:00

  • Anastomotic leak predicts diminished long-term survival after resection for gastric and esophageal cancer.

    abstract:BACKGROUND:Previous studies have reported on the association between perioperative morbidity and diminished oncologic outcomes in patients undergoing resection for colorectal or pancreatic cancer. However, the effect of anastomotic leak (AL) on the survival of patients with gastric or esophageal cancer remains unclear....


    pub_type: 杂志文章


    authors: Andreou A,Biebl M,Dadras M,Struecker B,Sauer IM,Thuss-Patience PC,Chopra S,Fikatas P,Bahra M,Seehofer D,Pratschke J,Schmidt SC

    更新日期:2016-07-01 00:00:00

  • Dexamethasone for postoperative hyperbilirubinemia in patients after liver resection: An open-label, randomized controlled trial.

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    authors: Huang C,Zhu XD,Shi GM,Shen YH,Ding GY,Cai JB,Zhou J,Fan J,Sun HC

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    authors: Mylonas KS,Reinhorn M,Ott LR,Westfal ML,Masiakos PT

    更新日期:2017-11-01 00:00:00

  • Occlusion of the innominate, common carotid, and subclavian arteries: long-term results of surgical treatment.

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    pub_type: 杂志文章


    authors: Crawford ES,Stowe CL,Powers RW Jr

    更新日期:1983-11-01 00:00:00

  • Influence of surgical margin on type of recurrence after liver resection for colorectal metastases: a single-center experience.

    abstract:BACKGROUND:Hepatectomy for colorectal liver metastases (CRLM) may offer good long-term survival. The impact of the tumor-free surgical margin on long-term results remains controversial, and we have assessed this component in 185 patients. METHODS:Between 1992 and 2005, 185 patients underwent primary hepatectomy with c...


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    authors: Nuzzo G,Giuliante F,Ardito F,Vellone M,Giovannini I,Federico B,Vecchio FM

    更新日期:2008-03-01 00:00:00

  • Acute cyclosporine-induced renal vasoconstriction is mediated by endothelin-1.

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    authors: Bloom IT,Bentley FR,Garrison RN

    更新日期:1993-08-01 00:00:00

  • Team training can improve operating room performance.

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    authors: Armour Forse R,Bramble JD,McQuillan R

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    更新日期:2010-04-01 00:00:00

  • Screening for primary hyperparathyroidism before thyroid surgery: A prospective study.

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    authors: Denizot A,Dadoun F,Meyer-Dutour A,Alliot P,Argème M

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    authors: Wu CC,Ho WL,Yeh DC,Huang CR,Liu TJ,P'eng FK

    更新日期:1996-07-01 00:00:00

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    pub_type: 杂志文章,评审


    authors: Watt DG,Horgan PG,McMillan DC

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    authors: Tajima Y,Tsutsumi R,Kuroki T,Mishima T,Adachi T,Kitasato A,Kanematsu T

    更新日期:2006-11-01 00:00:00

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    authors: Imai T,Tobinaga J,Morita-Matsuyama T,Kikumori T,Sasano H,Seo H,Funahashi H

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    pub_type: 杂志文章


    authors: Shimada S,Yagi Y,Shiomori K,Honmyo U,Hayashi N,Matsuo A,Marutsuka T,Ogawa M

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    pub_type: 杂志文章


    authors: Forster J,Monchik JM,Martin HF

    更新日期:1988-12-01 00:00:00

  • Chronic extrinsic denervation after small bowel transplantation in rat jejunum: Effects and adaptation in nitrergic and non-nitrergic neuromuscular inhibitory mechanisms.

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    pub_type: 杂志文章


    authors: Balsiger BM,Ohtani N,Anding WJ,Duenes JA,Sarr MG

    更新日期:2001-04-01 00:00:00