Factors influencing decisions by critical care physicians to withdraw life-sustaining treatments in critically ill adult patients with severe traumatic brain injury

• Published in: Canadian Medical Association journal (CMAJ) 2019-06, Vol.191 (24), p.E652-E663
• Main Authors: Turgeon, Alexis F, Dorrance, Kristin, Archambault, Patrick, Lauzier, François, Lamontagne, François, Zarychanski, Ryan, Fowler, Robert, Moore, Lynne, Lacroix, Jacques, English, Shane, Boutin, Amélie, Muscedere, John, Burns, Karen E A, Griesdale, Donald, McIntyre, Lauralyn A, Scales, Damon, Bernard, Francis, Yamada, Janet, Squires, Janet E
• Format: Article
• Language: English
• Subjects: Blood & organ donations; Brain injuries; Brain Injuries, Traumatic; Brain research; Canada; Care and treatment; Clinical Decision-Making; Critical Care; Critical care medicine; Critical Illness; Decision making; Euthanasia; Evidence-based medicine; Family; Female; Health psychology; Humans; Intensive care; Interviews; Male; Mortality; Patients; Physicians; Practice; Qualitative Research; Researchers; Surveys; Terminal care; Theory; Trauma; Trauma Severity Indices; Traumatic brain injury; Withholding Treatment
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.190154

Most deaths in critically ill patients with severe traumatic brain injury are associated with a decision to withdraw life-sustaining treatments. We aimed to identify the behavioural determinants that influence recommendations by critical care physicians to consider the withdrawal of life-sustaining treatments in this population. We conducted a descriptive qualitative study based on the Theoretical Domains Framework of critical care physicians caring for patients with severe traumatic brain injury across Canada. We stratified critical care physicians by regions and used a purposive sampling strategy. We conducted semistructured phone interviews using a piloted and pretested interview guide. We transcribed the interviews verbatim and verified the content for accuracy. We performed the analysis using a 3-step approach: coding, generation of specific beliefs and generation of specific themes. We recruited 20 critical care physicians across 4 geographic regions. After reaching saturation, we identified 7 core themes across 4 Theoretical Domains Framework domains for factors relevant to the decision to withdraw life-sustaining treatments. Four factors (i.e., clinical triggers, social triggers, interaction with families and intentions with medical decisions) were identified before the decision is made and 3 were identified during the decision-making process (i.e., considerations, priorities and knowledge needs). We identified multiple themes reflecting internal ( = 18, 8 Theoretical Domains Framework domains) and external ( = 15, 6 Theoretical Domains Framework domains) influences on the decision to withdraw life-sustaining treatments. We identified several core themes and domains considered by critical care physicians in Canada in the decision to withdraw life-sustaining treatments in critically ill patients with severe traumatic brain injury. Future research should aim at identifying the factors influencing surrogate decision-makers in the decision to withdraw life-sustaining treatments in these patients.