Sex-related differences in end-of-life decision-making in patients with traumatic brain injury: a systematic review and meta-analysis

Background: Families and medical professionals caring for traumatic brain injury (TBI) patients are often faced with decisions regarding the limitation of life-sustaining treatment (LLST). Considering difficulty of outcome prognostication and the resulting lack of objectivity, these decisions remain challenging. Although it is recognized that sex influences end-of-life care, research on sex differences in palliative care (PC) is scarce. To better understand the decision-making process at the end of life in TBI, we investigated potential sex-differences in the frequency of LLST and PC involvement, the extent of LLST, the timing of LLST and PC involvement, and the nature of the decisional authority that instigates the redirection of care. Methods: In this systematic review and meta-analysis, we conducted a literature search in PubMed and EMBASE on March 10th, 2025. We included randomized, interventional, observational, prospective, and retrospective studies published in English on adult patients with TBI. Eligible studies provided data on sex-related differences in the frequency of LLST and PC involvement, the extent of redirection of care, the timing of LLST and PC involvement, and the nature of the decisional authority. We performed a random-effects meta-analysis to assess sex differences in frequency of LLST and PC involvement. Risk of bias was evaluated with funnel plots and the Newcastle-Ottawa-Scale. Conclusions: Our results suggest that women with TBI are more likely to receive LLST and PC than men. This suggests that patient's sex plays a role in end-of-life decision-making. However, due to methodological limitations, our results must be interpreted with caution and highlight the need for further research. Trial registration: International prospective register for systematic reviews (PROSPERO; registration number CRD42025615274).