Racial Differences in Withdrawal of Mechanical Ventilation Do Not Alter Mortality in Neurologically Injured Patients

Overview

Journal J Crit Care

Specialty Critical Care

Date 2013 Oct 15

PMID 24120091

Citations 7

Authors

Michael A Rubin

Rajat Dhar

Michael N Diringer

Affiliations

Soon will be listed here.

Abstract

Purpose: Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities.

Materials And Methods: We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours.

Results: Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001).

Conclusions: Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.

Citing Articles

Palliative General Anesthesia at Terminal Extubation: "Go Gentle into that Good Night".

Lazaridis C Neurocrit Care. 2025; .

PMID: 40032772 DOI: 10.1007/s12028-025-02228-x.

An Investigation into the Public's Attitude Toward Opting out of Brain Death.

Ludka N, Hurse D, Brummett A Neurocrit Care. 2025; .

PMID: 39810074 DOI: 10.1007/s12028-024-02196-8.

Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review.

Hauschildt K, Vick J, Ashana D Crit Care Clin. 2024; 40(4):753-766.

PMID: 39218484 PMC: 11648938. DOI: 10.1016/j.ccc.2024.05.007.

Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study.

Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough C Neurology. 2023; 101(5):e558-e569.

PMID: 37290972 PMC: 10401677. DOI: 10.1212/WNL.0000000000207462.

Interpretability and fairness evaluation of deep learning models on MIMIC-IV dataset.

Meng C, Trinh L, Xu N, Enouen J, Liu Y Sci Rep. 2022; 12(1):7166.

PMID: 35504931 PMC: 9065125. DOI: 10.1038/s41598-022-11012-2.

References

Liu V, Bhattacharya J, Weill D, Hlatky M . Persistent racial disparities in survival after heart transplantation. Circulation. 2011; 123(15):1642-9. PMC: 3125110. DOI: 10.1161/CIRCULATIONAHA.110.976811. View

Curtis J, Vincent J . Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010; 376(9749):1347-53. DOI: 10.1016/S0140-6736(10)60143-2. View

Mayer S, Kossoff S . Withdrawal of life support in the neurological intensive care unit. Neurology. 1999; 52(8):1602-9. DOI: 10.1212/wnl.52.8.1602. View

Degenholtz H, Thomas S, Miller M . Race and the intensive care unit: disparities and preferences for end-of-life care. Crit Care Med. 2003; 31(5 Suppl):S373-8. DOI: 10.1097/01.CCM.0000065121.62144.0D. View

Nelson A . Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002; 94(8):666-8. PMC: 2594273. View

Boyd E, Lo B, Evans L, Malvar G, Apatira L, Luce J . "It's not just what the doctor tells me:" factors that influence surrogate decision-makers' perceptions of prognosis. Crit Care Med. 2010; 38(5):1270-5. PMC: 3530838. DOI: 10.1097/CCM.0b013e3181d8a217. View

Zhang A, Zyzanski S, Siminoff L . Ethnic differences in the caregiver's attitudes and preferences about the treatment and care of advanced lung cancer patients. Psychooncology. 2011; 21(11):1250-3. PMC: 3612394. DOI: 10.1002/pon.2031. View

Koch K, Rodeffer H, Wears R . Changing patterns of terminal care management in an intensive care unit. Crit Care Med. 1994; 22(2):233-43. DOI: 10.1097/00003246-199402000-00013. View

Peek M, Odoms-Young A, Quinn M, Gorawara-Bhat R, Wilson S, Chin M . Race and shared decision-making: perspectives of African-Americans with diabetes. Soc Sci Med. 2010; 71(1):1-9. PMC: 2885527. DOI: 10.1016/j.socscimed.2010.03.014. View

10.

Pines J, Russell Localio A, Hollander J . Racial disparities in emergency department length of stay for admitted patients in the United States. Acad Emerg Med. 2009; 16(5):403-10. DOI: 10.1111/j.1553-2712.2009.00381.x. View

11.

Diringer M, Edwards D, Aiyagari V, Hollingsworth H . Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit. Crit Care Med. 2001; 29(9):1792-7. DOI: 10.1097/00003246-200109000-00023. View

12.

Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L . Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003; 349(12):1123-32. DOI: 10.1056/NEJMoa030083. View

13.

Do D, Frank R, Finch B . Does SES explain more of the black/white health gap than we thought? Revisiting our approach toward understanding racial disparities in health. Soc Sci Med. 2012; 74(9):1385-93. DOI: 10.1016/j.socscimed.2011.12.048. View

14.

Balsa A, McGuire T, Meredith L . Testing for statistical discrimination in health care. Health Serv Res. 2005; 40(1):227-52. PMC: 1361135. DOI: 10.1111/j.1475-6773.2005.00351.x. View

15.

Keppel K, Pearcy J, Heron M . Is there progress toward eliminating racial/ethnic disparities in the leading causes of death?. Public Health Rep. 2010; 125(5):689-97. PMC: 2925005. DOI: 10.1177/003335491012500511. View

16.

Prendergast T, Luce J . Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med. 1997; 155(1):15-20. DOI: 10.1164/ajrccm.155.1.9001282. View

17.

Fawole O, Dy S, Wilson R, Lau B, Martinez K, Apostol C . A systematic review of communication quality improvement interventions for patients with advanced and serious illness. J Gen Intern Med. 2012; 28(4):570-7. PMC: 3599019. DOI: 10.1007/s11606-012-2204-4. View

18.

Lubitz J, Riley G . Trends in Medicare payments in the last year of life. N Engl J Med. 1993; 328(15):1092-6. DOI: 10.1056/NEJM199304153281506. View

19.

Cooper Z, Rivara F, Wang J, MacKenzie E, Jurkovich G . Racial disparities in intensity of care at the end-of-life: are trauma patients the same as the rest?. J Health Care Poor Underserved. 2012; 23(2):857-74. DOI: 10.1353/hpu.2012.0064. View

20.

Welch L, Teno J, Mor V . End-of-life care in black and white: race matters for medical care of dying patients and their families. J Am Geriatr Soc. 2005; 53(7):1145-53. DOI: 10.1111/j.1532-5415.2005.53357.x. View