Elsevier

Resuscitation

Volume 85, Issue 11, November 2014, Pages 1455-1461
Resuscitation

Clinical Paper
Predictors of early care withdrawal following out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2014.08.030Get rights and content

Abstract

Aims

To identify factors that associated with early care withdrawal in out-of-hospital cardiac arrest patients.

Methods

Data was collected from 189 survivors to hospital admission. Patients were classified by survival status upon hospital discharge, and those who died were categorized into withdrawal vs. no withdrawal of care. Those who had care withdrawn were further subdivided into early care withdrawal i.e. ≤72 h vs. late withdrawal >72 h. Multivariable adjusted odds ratios were used to assess factors associated with early care withdrawal.

Results

Of 189 patients with cardiac arrest, only 36 had advanced directives (19%) and 99 (52%) had care withdrawn. Most patients whose care was withdrawn died in hospital (94/99, 95%), and the remainder died in hospice. Care was withdrawn early ≤72 h in the majority of patients (59/94, 63%). Median time to early care withdrawal was 2 days IQR (1–3). Factors associated with early care withdrawal were age ≥75 years, poor initial neurologic exam, multiple co morbidities, multi-organ failure, lactic acid ≥10 mmol L−1, Caucasian race and absence of bystander CPR. Advance directives did not appear to determine early care withdrawal.

Conclusions

Although most cardiac arrest patients do not have advance directives, care is often withdrawn in more than 50% and in many before the accepted time for neurological awakening (72 h). The decision to withdraw care is influenced by older age, race, preexisting co morbidities, multi-organ failure, and a poor initial neurological exam. Further studies are needed to better understand this phenomenon and other sociological factors that guide such decisions.

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.

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