Clinical PaperPredictors of early care withdrawal following out-of-hospital cardiac arrest
Introduction
More than 400,000 cardiac arrests occur annually in the United States with an overall survival rate to hospital discharge of only 10.4%.1 Despite many advances in resuscitation care, death in such patients is likely a reflection of severity of illness, multiple co-morbidities, and withdrawal of life sustaining therapy after survival to hospital admission.
Care withdrawal is often an emotionally charged complex decision that is likely guided and influenced by patients’ family beliefs and physician reports on outcome prediction. Multiple studies have put forward prognostication tools to help guide decision making.2, 3, 4 These studies demonstrated that maximal neurological recovery generally occurs within the first 3 days following anoxic insult; hence, the practice emerged to wait 72 h before making a prediction on outcome.2, 3 Other studies have commented on the possibility of prognostication as early as 24 h following cardiac arrest.4, 5, 6 However, following the broad application of therapeutic hypothermia into clinical practice, some studies have reported delayed awakening in patients treated with hypothermia after cardiac arrest.7, 8 Therefore, the question of the appropriate and optimal timing for accurate prognostication to guide clinical care decisions has become more challenging and remains in dispute but is generally accepted to be at least 3 days post arrest.
Although withdrawal of care has been well studied in medical ICU patients,9, 10 following traumatic brain injury and subarachnoid hemorrhage,11, 12 little is known about the timing of such a clinical decision in post cardiac arrest patients. Therefore, we conducted this study to better understand timing of care withdrawal post cardiac arrest and to further identify factors that guide this critical decision.
Section snippets
Setting and study design
The study was conducted at an academic teaching medical center in Baltimore, Maryland that serves a population of more than one million of which 60.8% are Caucasian, 30% are African-American, 6% are Asian and 3.2% of other ethnicities. The medical center has 24-cardiac/medical intensive care unit beds, and serves a mixed urban community where EMS has a 2-tiered response system with first responders being AED equipped.
Following Institutional Review Board (IRB) approval, data were collected using
Patient characteristics
During the study period 189 non-traumatic out of hospital cardiac arrest patients who met inclusion criteria were admitted to the intensive care unit. Of these 107 (57%) were male, 137 (72.5%) were Caucasian and 52 (27.5%) were black. Mean age was 64 ± 14 years. Only 36 had advanced directives (19%). During the first 24 h, 149 patients (79%) had an unfavorable brainstem reflex score of <3. A total of 99/189 patients (52%) had care withdrawn whether early (≤72 h) or late (>72 h) (Table 1).
Out of the
Discussion
The Ethicus study, conducted in 37 ICUs in 17 European countries, demonstrated that withdrawing and withholding life sustaining treatments contributed to the majority of deaths (72%) in critically ill patients10. However, few studies have commented on care withdrawal following out-of-hospital cardiac arrest.19, 20, 21
This study was designed to address the following critical issues: how often is care withdrawn, and if so when, on whom and why? We also sought to identify clinical features and
Limitations
This study has several limitations that are worthy of comment. First, this study reflects a single institution experience which may limit the generalizability of the results given the variability of withdrawing life sustaining treatments in critically ill patients between regions, cultures and religions. Second, although reporting in nearly 200 patients, the study could be strengthened by a larger sample size. Third, the role of religious and social factors in making the decision of care
Conclusion
The results emphasize that in more than 60% of patients, care is withdrawn before the accepted time for neurological awakening (72 h) and appears to be influenced by advanced age, poor initial neurological exam, multiple co morbidities, multi-organ failure, Caucasian race and the absence of bystander CPR. Further investigations are necessary to elucidate the magnitude of the effect that family wishes, physicians’ prognostication, and complex social factors have on the delicate and critical
Funding sources
Dr. Dhananjay Vaidya was supported by NIH grant UL1TR001079 through the Johns Hopkins Institute for Clinical and Translational Research.
Conflict of interest statement
Aiham Albaeni, Shaker Eid, Dhananjay Vaidya, and Nisha Chandra-Strobos declare that they have no conflict of interest.
Acknowledgements
None.
References (28)
- et al.
Prediction protocol for neurological outcome for survivors of out-of-hospital cardiac arrest treated with targeted temperature management
Resuscitation
(2012) - et al.
Time to awakening and neurologic outcome in therapeutic hypothermia-treated cardiac arrest patients
Resuscitation
(2013) - et al.
Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early?
Resuscitation
(2014) - et al.
Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest
Resuscitation
(2014) - et al.
The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU
Chest
(2011) - et al.
The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest
Resuscitation
(2013) - et al.
Cardiopulmonary resuscitation directives on admission to intensive-care unit: an international observational study
Lancet
(2001) - et al.
Withholding and withdrawal of life support in intensive-care units in France: A prospective survey. French LATAREA group
Lancet
(2001) - et al.
Limitation of life support after resuscitation from cardiac arrest: practice in Belgium and Austria
Resuscitation
(1997) - et al.
Heart disease and stroke statistics—2014 update: a report from the American Heart Association
Circulation
(2014)
Predicting outcome from hypoxic-ischemic coma
JAMA
Quality standards subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology
Neurology
Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest
JAMA
Predicting survival with good neurological outcome within 24 hours following out of hospital cardiac arrest: the application and validation of a novel clinical score
J Neurol Transl Neurosci
Cited by (26)
Determinants of change in code status among patients with cardiopulmonary arrest admitted to the intensive care unit
2022, ResuscitationCitation Excerpt :Of note, previous studies have demonstrated that racial and ethnic minorities are more likely to be admitted to the intensive care unit, have prolonged stays, and have a higher index of intensive non-curative treatment 3,4. Hispanic and African American patients are more likely to receive cardiopulmonary resuscitation (CPR) and undergo longer periods with mechanical ventilation 4–6, while younger patients and patients with fewer comorbidities are less likely to have withdrawal of care 7,8. When focusing on advanced directives in the outpatient setting, studies of elderly patients have demonstrated lower rates of these directives among patients from ethnic backgrounds compared to White patients6.
Withdrawal of life-sustaining therapy in intensive care unit patients following out-of-hospital cardiac arrest: An Australian metropolitan ICU experience
2022, Heart and LungCitation Excerpt :The significant mortality outcome confirms previously published evidence of the role of WLST as a common mode of death in OHCA patients.8 In comparison to previous research by Albaeni et al.22 in the United States in 2014, our study reported higher rates of WLST and mortality. The key to explaining this discrepancy required us to retrospectively review the growing research of withdrawal practices between 2006 and 2015.24
Palliative care utilization following out-of-hospital cardiac arrest in the United States
2018, ResuscitationCitation Excerpt :In addition, female gender and Caucasian race were also noted to be associated with an increased likelihood of PC utilization. A similar phenomenon was also reported in PC use following intracranial hemorrhage [5] and in care withdrawal decisions following cardiac arrest [21]. Hospital related factors such as hospital region, bed size, teaching status, and location in urban areas all appeared to influence the decision to initiate palliative care.