Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

Overview

Journal Stroke

Specialties Cardiology & Vascular Diseases
Neurology

Date 2021 Sep 29

PMID 34583530

Citations 21

Authors

Ayham Alkhachroum

Antonio J Bustillo

Negar Asdaghi

Erika Marulanda-Londono

Carolina M Gutierrez

Daniel Samano

Evie Sobczak

Dianne Foster

Mohan Kottapally

Amedeo Merenda

Sebastian Koch

Jose G Romano

Kristine OPhelan

Jan Claassen

Ralph L Sacco

Tatjana Rundek

Affiliations

Soon will be listed here.

Abstract

Background And Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST).

Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition.

Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate.

Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

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References

Claassen J, Doyle K, Matory A, Couch C, Burger K, Velazquez A . Detection of Brain Activation in Unresponsive Patients with Acute Brain Injury. N Engl J Med. 2019; 380(26):2497-2505. DOI: 10.1056/NEJMoa1812757. View

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

Morgenstern L, Hemphill 3rd J, Anderson C, Becker K, Broderick J, Connolly Jr E . Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010; 41(9):2108-29. PMC: 4462131. DOI: 10.1161/STR.0b013e3181ec611b. View

Varelas P, Abdelhak T, Hacein-Bey L . Withdrawal of life-sustaining therapies and brain death in the intensive care unit. Semin Neurol. 2008; 28(5):726-35. DOI: 10.1055/s-0028-1105969. View

Wahlster S, Sharma M, Chu F, Granstein J, Johnson N, Longstreth W . Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care. 2020; 34(3):956-967. PMC: 8363498. DOI: 10.1007/s12028-020-01109-9. View

Hemphill 3rd J, Newman J, Zhao S, Johnston S . Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004; 35(5):1130-4. DOI: 10.1161/01.STR.0000125858.71051.ca. View

MacKinnon D, Cox M . Commentary on "Mediation Analysis and Categorical Variables: The Final Frontier" by Dawn Iacobucci. J Consum Psychol. 2012; 22(4):600-602. PMC: 3501728. DOI: 10.1016/j.jcps.2012.03.009. View

Asdaghi N, Romano J, Wang K, Ciliberti-Vargas M, Koch S, Gardener H . Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Stroke. 2016; 47(10):2618-26. PMC: 5039084. DOI: 10.1161/STROKEAHA.116.013059. View

Elmer J, Torres C, Aufderheide T, Austin M, Callaway C, Golan E . Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest. Resuscitation. 2016; 102:127-35. PMC: 4834233. DOI: 10.1016/j.resuscitation.2016.01.016. View

10.

Verkade M, Epker J, Nieuwenhoff M, Bakker J, Kompanje E . Withdrawal of life-sustaining treatment in a mixed intensive care unit: most common in patients with catastropic brain injury. Neurocrit Care. 2011; 16(1):130-5. DOI: 10.1007/s12028-011-9567-y. View

11.

Wabl R, Williamson C, Pandey A, Rajajee V . Long-term and delayed functional recovery in patients with severe cerebrovascular and traumatic brain injury requiring tracheostomy. J Neurosurg. 2018; 131(1):114-121. DOI: 10.3171/2018.2.JNS173247. View

12.

Naidech A, Bernstein R, Bassin S, Garg R, Liebling S, Bendok B . How patients die after intracerebral hemorrhage. Neurocrit Care. 2009; 11(1):45-9. DOI: 10.1007/s12028-009-9186-z. View

13.

Navarrete-Navarro P, Rivera-Fernandez R, Lopez-Mutuberria M, Galindo I, Murillo F, Dominguez J . Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain). Intensive Care Med. 2003; 29(8):1237-44. DOI: 10.1007/s00134-003-1755-6. View

14.

Lazaridis C . Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty. Neurocrit Care. 2018; 30(1):33-41. DOI: 10.1007/s12028-018-0595-8. View

15.

Zahuranec D, Morgenstern L, Sanchez B, Resnicow K, White D, Hemphill 3rd J . Do-not-resuscitate orders and predictive models after intracerebral hemorrhage. Neurology. 2010; 75(7):626-33. PMC: 2931769. DOI: 10.1212/WNL.0b013e3181ed9cc9. View

16.

Weimer J, Nowacki A, Frontera J . Withdrawal of Life-Sustaining Therapy in Patients With Intracranial Hemorrhage: Self-Fulfilling Prophecy or Accurate Prediction of Outcome?. Crit Care Med. 2016; 44(6):1161-72. DOI: 10.1097/CCM.0000000000001570. View

17.

Hemphill 3rd J, Greenberg S, Anderson C, Becker K, Bendok B, Cushman M . Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015; 46(7):2032-60. DOI: 10.1161/STR.0000000000000069. View

18.

Zahuranec D, Brown D, Lisabeth L, Gonzales N, Longwell P, Smith M . Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology. 2007; 68(20):1651-7. DOI: 10.1212/01.wnl.0000261906.93238.72. View

19.

Smaha L . The American Heart Association Get With The Guidelines program. Am Heart J. 2004; 148(5 Suppl):S46-8. DOI: 10.1016/j.ahj.2004.09.015. View

20.

Becker K, Baxter A, Cohen W, Bybee H, Tirschwell D, Newell D . Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001; 56(6):766-72. DOI: 10.1212/wnl.56.6.766. View