A Propensity-Matched Comparison of Capacity for Functional Recovery by 24 Months Post-traumatic Brain Injury in Patients Who Died After Withdrawal of Life-Sustaining Therapy

BACKGROUND AND OBJECTIVES: We sought to extend recent findings that severe traumatic brain injury (TBI) patients (Glasgow Coma Scale ≤8) whose care was withdrawn may have had opportunities to improve their functional ability. The objectives were to (1) evaluate recovery potential up to 24 months postinjury, (2) quantify the magnitude of change in functional outcome over time, and (3) assessing the frequency of shifting function from fully dependent [Glasgow Outcome Scale Extended (GOSE) = 2-3] to at least partial independence (GOSE >3; independent for 8+ hours/day) over time. METHODS: This is a secondary analysis of a prospectively collected database of patients from a single level 1 trauma center (n = 535). Mortality (yes/no) and morbidity ("unfavorable outcome": GOSE = 1-3 vs "favorable outcome": GOSE = 4-8) were recorded at 3-, 6-, 12-, and 24 months. Participants whose life-sustaining therapies were withdrawn (WLST+; n = 100) were 1:3 propensity matched to patients whose care was not withdrawn (WLST-; n = 334). A weighted and cross-validated point estimate and 1-sample weighted binomial test for change in GOSE from 3-, 6-, and 12 months to 24 months was derived for TBI survivors in the overall matched WLST- cohort and by propensity score Tier. RESULTS: Within WLST- cohort, 15.0% of followed participants had died by 24 months postinjury (n = 50/334). In the overall WLST- cohort, 38.3% (95% CI: 0.26-0.51, P < .0001) improved from GOSE = 2-3 at 3 months to GOSE ≥4 at 24 months. Improvements to GOSE ≥4 at 24 months were also observed in dependent TBI survivors from 6 months (24.5%, 95% CI: 0.14-0.26, P < .0001) and 12 months postinjury (13.1%, 95% CI: 0.05-21.8, P = .005). CONCLUSION: In this single-center cohort, a meaningful proportion of severe TBI patients whose life-sustaining care was withdrawn could have recovered at least partial independence by 24 months postinjury.