# Factors influencing withdrawal of life-sustaining treatments in patients with severe acquired brain injuries: a scoping review

## TL;DR

This study reviews factors influencing the withdrawal of life-sustaining treatments in patients with severe brain injuries, highlighting age, prognosis, and race as key predictors.

## Contribution

The study provides a comprehensive scoping review of factors influencing WLST decisions in ABI patients, emphasizing potential biases and disparities.

## Key findings

- Older age consistently emerged as a determinant for withdrawal of life-sustaining treatments.
- Race, socioeconomic status, and institutional policies contribute to disparities in WLST practices.
- Prognostic uncertainty and clinical severity independently influence WLST decisions.

## Abstract

Withdrawal of life-sustaining treatments (WLST) is a leading cause of death in patients with severe acquired brain injuries (ABI). These decisions often occur under conditions of prognostic uncertainty and time-critical therapeutic windows and may be shaped by a complex interplay of factors. Elucidating these influences is essential to ensure that WLST decisions are made in an informed, unbiased, and transparent manner, and in alignment with wishes of the patients as well as their surrogate decision makers.

Conduct a scoping review of literature to identify, elaborate and analyze the various factors that influence decisions to WLST in adult patients with ABI. This review aims to provide a comprehensive understanding of current practices.

This scoping review, conducted according to PRISMA-ScR guidelines, examined literature on WLST in adult ABI, in whom brain death had not been declared. The search was conducted in PubMed and Web of Science, up to August 2024. Studies were screened by title/abstract and full text, with data systematically extracted. Only original, peer-reviewed articles focusing on WLST in adult severe ABI patients were included. N = 2,963 independent papers were initially found, of which N = 2,881 were excluded. A final count of N = 81 independent papers were included.

Demographic factors (age, sex, race, socioeconomic status, etc.; n = 50), prognosis and clinical factors (n = 59), family preferences (n = 28), physician-related factors and institutional context (n = 31), formal medical directive (n = 13), ethical/legal frameworks (n = 13), geographical differences (n = 9) and religious beliefs (n = 5) all played pivotal roles in WLST decisions. Older age consistently emerged as a determinant for WLST, as well as poor prognosis and white race.

WLST decisions are most often made for older adults, with age consistently identified as a key predictor, independent of the clinical severity of ABI. Additional factors such as race, socioeconomic status, advance directives, and variations in healthcare provider attitudes and institutional policies further contribute to disparities in WLST practices. Understanding these intersecting influences is essential to recognizing potential biases and promoting more equitable, patient-centered end-of-life decision-making.