Clinical Context: Withdrawal of Life-Sustaining Therapy and Long-Term Recovery in Severe Traumatic Brain Injury

Severe traumatic brain injury (TBI) forces clinicians to make irreversible decisions in the setting of profound uncertainty. Early neurologic examinations are limited by sedation, physiologic instability, and evolving injury, yet discussions about withdrawal of life-sustaining therapy (WLST) often occur within the first several days after injury. Once life-sustaining therapy is withdrawn, recovery is no longer possible.

Those dynamics are examined in, “A Propensity-Matched Comparison of Capacity for Functional Recovery by 24 Months Post-traumatic Brain Injury in Patients Who Died After Withdrawl of Life-Sustaining Therapy,” a study led by Shawn Eagle, PhD, assistant professor of neurological surgery at the University of Pittsburgh School of Medicine, and senior author, David Okonkwo, MD, PhD, professor of neurological surgery and clinical director of neurotrauma at UPMC. Using prospectively collected data from the University of Pittsburgh, the study shows that meaningful functional recovery can emerge well beyond early prognostic timepoints and that early clinical assessments do not reliably define long-term outcome.

John Kanter, MD, assistant professor of neurological surgery and a UPMC neurosurgeon who is dual fellowship-trained in neurocritical care and neurotrauma.

“TRACK-TBI, a longitudinal study of patients with TBI of which the University of Pittsburgh was a key site, fundamentally changed how we think about traumatic brain injury, not just in terms of treatment, but prognosis,” Dr. Kanter says. “What this manuscript does well is that it is very balanced. It does not overstate the findings. It acknowledges what we do not know, which is that as clinicians, with the science we have, we cannot reliably prognosticate in the acute period,” Dr. Kanter says.

The mismatch between prognostic uncertainty and the timing of WLST decisions has real consequences. Nationally, withdrawal of life-sustaining therapy frequently occurs within the first week after severe traumatic brain injury, often before neurologic trajectories have had time to declare themselves. Outcomes can depend as much on clinician practice patterns as on injury severity.

“There are data showing that survival can depend on who is on call,” Dr. Kanter says. “If someone is nihilistic, withdrawal of life-sustaining therapy can happen very early. On average, it happens within a few days, and by seven days, more than half of patients nationally have had life-sustaining therapy withdrawn,” Dr. Kanter says.

At UPMC, the clinical approach has historically allowed more time before irreversible decisions are made, reflecting recognition that severe traumatic brain injury is not an acute event but a condition with a prolonged and evolving course.

“When you take a deliberately anti-nihilistic approach and give patients time, not only do more people survive, but a meaningful number recover to a level of functional independence,” Dr. Kanter says. “Some are independent at home for part of the day. That difference matters,” Dr. Kanter says.

Functional recovery extends beyond the individual patient. Partial independence can reduce the need for continuous caregiving, allow family members to return to work, and mitigate the broader social and economic consequences of traumatic brain injury.

“That matters for the patient’s sense of self, for their family, and for the community,” Dr. Kanter says. “Traumatic brain injury is not just a single-person problem. It is a community problem,” Dr. Kanter says.

The study does not argue for indiscriminate prolongation of care. It reinforces respect for patient autonomy and acknowledges that withdrawal of life-sustaining therapy may be appropriate when aligned with patient values. Its contribution lies in quantifying how often recovery occurs later than early prognostic frameworks allow and in supporting a more temporally informed approach to decision making.

“This kind of work gives us the ability to say that we do not yet know who will recover,” Dr. Kanter says. “But if we give patients time, we can affect change, and some will have outcomes that are far better than early assessments would suggest,” Dr. Kanter says.

Read the summary article on Dr. Eagle and colleague's study.

Reference

Eagle SR, Yue JK, Shanahan RM, Shim J, Puccio AM, Okonkwo DO. A Propensity-Matched Comparison of Capacity for Functional Recovery by 24 Months Post-traumatic Brain Injury in Patients Who Died After Withdrawl of Life-Sustaining Therapy. Neurosurgery. 2026; 00: 1-10 Online ahead of print.