Abstract
Background
Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH.
Methods
Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis.
Results
The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160–1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022–1.068, p < 0.001) with the latter also impacting early WOLST decisions.
Conclusions
Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.
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References
Shea AM, Reed SD, Curtis LH, Alexander MJ, Villani JJ, Schulman KA. Characteristics of nontraumatic subarachnoid hemorrhage in the United States in 2003. Neurosurgery. 2007;61(6):1131–7 discussion 1137–1138.
Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery. 2002;51(5):1101–5 discussion 1105–1107.
Smith EE, Shobha N, Dai D, et al. A risk score for in-hospital death in patients admitted with ischemic or hemorrhagic stroke. J Am Heart Assoc. 2013;2(1):e005207.
Qureshi AI, Suri MF, Nasar A, et al. Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States. Neurosurgery. 2005;57(1):1–8 discussion 1–8.
van den Berg R, Foumani M, Schroder RD, et al. Predictors of outcome in world federation of neurologic surgeons grade V aneurysmal subarachnoid hemorrhage patients. Crit Care Med. 2011;39(12):2722–7.
Cross DT 3rd, Tirschwell DL, Clark MA, et al. Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states. J Neurosurg. 2003;99(5):810–7.
Naval NS, Chang T, Caserta F, Kowalski RG, Carhuapoma JR, Tamargo RJ. Improved aneurysmal subarachnoid hemorrhage outcomes: a comparison of 2 decades at an academic center. J Crit Care. 2013;28(2):182–8.
Rinkel GJ, Algra A. Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage. Lancet Neurol. 2011;10(4):349–56.
van Heuven AW, Dorhout Mees SM, Algra A, Rinkel GJ. Validation of a prognostic subarachnoid hemorrhage grading scale derived directly from the glasgow coma scale. Stroke. 2008;39(4):1347–8.
Starke RM, Komotar RJ, Kim GH, et al. Evaluation of a revised glasgow coma score scale in predicting long-term outcome of poor grade aneurysmal subarachnoid hemorrhage patients. J Clin Neurosci. 2009;16(7):894–9.
Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766–72.
Rosenberg NF, Liebling SM, Kosteva AR, Maas MB, Prabhakaran S, Naidech AM. Infarct volume predicts delayed recovery in patients with subarachnoid hemorrhage and severe neurological deficits. Neurocrit Care. 2013. doi:10.1007/s12028-013-9869-3.
Hemphill JC 3rd, White DB. Clinical nihilism in neuroemergencies. Emerg Med Clin North Am. 2009;27(1):27–37 vii–viii.
Turgeon AF, Lauzier F, Simard JF, et al. Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ. 2011;183(14):1581–8.
Schwarze ML, Bradley CT, Brasel KJ. Surgical “buy-in”: the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med. 2010;38(3):843–8.
Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ. Surgeons expect patients to buy-into postoperative life support preoperatively: results of a national survey. Crit Care Med. 2013;41(1):1–8.
Schwarze ML, Redmann AJ, Brasel KJ, Alexander GC. The role of surgeon error in withdrawal of postoperative life support. Ann Surg. 2012;256(1):10–5.
Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest. 2011;139(5):1025–33.
Johnson RW, Newby LK, Granger CB, et al. Differences in level of care at the end of life according to race. Am J Crit Care. 2010;19(4):335–43 quiz 344.
Bardach N, Zhao S, Pantilat S, Johnston SC. Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities. Am J Med. 2005;118(4):400–8.
Hemphill JC 3rd, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004;35(5):1130–4.
O’Callahan JG, Fink C, Pitts LH, Luce JM. Withholding and withdrawing of life support from patients with severe head injury. Crit Care Med. 1995;23(9):1567–75.
Cote N, Turgeon AF, Lauzier F, et al. Factors associated with the withdrawal of life-sustaining therapies in patients with severe traumatic brain injury: a multicenter cohort study. Neurocrit Care. 2013;18(1):154–60.
Franklin GA, Cannon RW, Smith JW, Harbrecht BG, Miller FB, Richardson JD. Impact of withdrawal of care and futile care on trauma mortality. Surgery. 2011;150(4):854–60.
Mayer SA, Kossoff SB. Withdrawal of life support in the neurological intensive care unit. Neurology. 1999;52(8):1602–9.
Varelas PN, 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.
Diringer MN, Edwards DF, 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.
Naval NS, Kowalski RG, Chang TR, Caserta F, Carhuapoma JR, Tamargo RJ. The SAH score: a comprehensive communication tool. J Stroke Cerebrovasc Dis. 2013. doi:10.1016/j.jstrokecerebrovasdis.2013.07.035.
Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211–40.
Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007;38(8):2315–21.
Wartenberg KE. Critical care of poor-grade subarachnoid hemorrhage. Curr Opin Crit Care. 2011;17(2):85–93.
Mocco J, Ransom ER, Komotar RJ, et al. Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery. 2006;59(3):529–38 discussion 529–538.
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Kowalski, R.G., Chang, T.R., Carhuapoma, J.R. et al. Withdrawal of Technological Life Support Following Subarachnoid Hemorrhage. Neurocrit Care 19, 269–275 (2013). https://doi.org/10.1007/s12028-013-9929-8
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DOI: https://doi.org/10.1007/s12028-013-9929-8