Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest

Jonathan Elmer; Cesar Torres; Tom P Aufderheide; Michael A Austin; Clifton W Callaway; Eyal Golan; Heather Herren; Jamie Jasti; Peter J Kudenchuk; Damon C Scales; Dion Stub; Derek K Richardson; Dana M Zive; Resuscitation Outcomes Consortium

doi:10.1016/j.resuscitation.2016.01.016

Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest

Resuscitation. 2016 May:102:127-35. doi: 10.1016/j.resuscitation.2016.01.016. Epub 2016 Feb 3.

Authors

Affiliations

¹ Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA; Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA. Electronic address: elmerjp@upmc.edu.
² Department of Biostatistics, University of Washington, F-600, Health Sciences Building, NE Pacific Street, Seattle, WA 98195, USA.
³ Department of Emergency Medicine, Medical College of Wisconsin, 9200W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
⁴ Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Associate Medical Director Regional Paramedic Program Eastern Ontario, Canada.
⁵ Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA.
⁶ Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada; Critical Care Medicine, University Health Network, 399 Bathurst Street, Room 2MCL-411J, M5T-2S8, Toronto, ON, Canada.
⁷ Resuscitations Outcome Consortium Clinical Trial Center, University of Washington, 1107 NE 45th St., Suite 505, Seattle, WA 98105-4680, USA.
⁸ Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6422, USA.
⁹ Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON, Canada M4 N 3M5.
¹⁰ St Paul's Hospital, Vancouver, BC, Canada; Baker IDI Institute Heart and Diabetes Institute, Melbourne, Australia.
¹¹ Department of Emergency Medicine, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA.
¹² Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code CDW-EM, Portland, OR 97239, USA.

PMID: 26836944
PMCID: PMC4834233
DOI: 10.1016/j.resuscitation.2016.01.016

Abstract

Background: Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after out-of-hospital cardiac arrest (OHCA). Although current guidelines recommend against WLST-N before 72h (WLST-N<72), this practice is common and may increase mortality. We sought to quantify these effects.

Methods: In a secondary analysis of a multicenter OHCA trial, we evaluated survival to hospital discharge and survival with favorable functional status (modified Rankin Score ≤3) in adults alive >1h after hospital admission. Propensity score modeling the probability of exposure to WLST-N<72 based on pre-exposure covariates was used to match unexposed subjects with those exposed to WLST-N<72. We determined the probability of survival and functionally favorable survival in the unexposed matched cohort, fit adjusted logistic regression models to predict outcomes in this group, and then used these models to predict outcomes in the exposed cohort. Combining these findings with current epidemiologic statistics we estimated mortality nationally that is associated with WLST-N<72.

Results: Of 16,875 OHCA subjects, 4265 (25%) met inclusion criteria. WLST-N<72 occurred in one-third of subjects who died in-hospital. Adjusted analyses predicted that exposed subjects would have 26% survival and 16% functionally favorable survival if WLST-N<72 did not occur. Extrapolated nationally, WLST-N<72 may be associated with mortality in approximately 2300 Americans each year of whom nearly 1500 (64%) might have had functional recovery.

Conclusions: After OHCA, death following WLST-N<72 may be common and is potentially avoidable. Reducing WLST-N<72 has national public health implications and may afford an opportunity to decrease mortality after OHCA.

Keywords: Cardiac arrest; Neurological prognosis; Prognostication; Resuscitation; Withdrawal of care.

Publication types

Multicenter Study
Randomized Controlled Trial
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Cardiopulmonary Resuscitation*
Emergency Medical Services / statistics & numerical data*
Female
Follow-Up Studies
Humans
Male
Middle Aged
Nervous System Diseases / epidemiology*
Nervous System Diseases / etiology
Out-of-Hospital Cardiac Arrest / complications
Out-of-Hospital Cardiac Arrest / mortality
Out-of-Hospital Cardiac Arrest / therapy*
Prognosis
Retrospective Studies
Survival Rate / trends
Time Factors
United States / epidemiology
Withholding Treatment*

Abstract

Publication types

MeSH terms

Grants and funding