Goals of care are rarely discussed prior to potentially futile trauma transfer: Is it okay to say “No”?

BACKGROUND: It is unknown how often the physician-to-physician trauma transfer conversation includes a discussion of patient goals of care (GOC). We hypothesized that physicians would rarely discuss GOC on transfer calls when faced with patients with catastrophic injuries. METHODS: We completed a retrospective case series of trauma patients transferred to an ACS-verified Level I trauma center between 2018 and 2022 who died or were discharged to hospice without surgical intervention within 48 hours. Transfer call recordings were analyzed for GOC conversations. RESULTS: A total of 5,562 patients were accepted as transfers and 82 (1.5%) met inclusion criteria. Eighty of the 82 patients had recorded transfer calls and were analyzed. The most common transfer reason was traumatic brain injury (TBI) and need for neurosurgical capabilities (53%) followed by complex multisystem trauma (23%). There was explicit discussion of code status prior to transfer in 20% and a more in depth GOC conversation for 10% of patients. Appropriateness of transfer was discussed in 21% and at least one physician expressed explicit concerns of futility for 14%, though all were subsequently transferred. Code status was changed immediately upon arrival for 15% for patients and 19% of patients transferred for neurosurgical expertise were deemed to have non-survivable injuries based on imaging and examination that were unchanged from the referring hospital. CONCLUSION: Among a group of profoundly injured trauma patients at high risk of death, an explicit discussion of GOC occurred in just 10%. This suggests that even when the catastrophic nature of patient injury is understood, transfers still occur, and patients and their families are subjected to an expensive, disruptive, and displacing experience with little to no anticipated benefit. A discussion of GOC and therapeutic objectives should be considered in all severely injured trauma patients prior to transfer.