Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest

RESUSCITATION

卷:102

Article

Elmer, Jonathan^1,2  Torres, Cesar³  Aufderheide, Tom P.⁴  Austin, Michael A.^5,16  Callaway, Clifton W.²  Golan, Eyal^6,7,8  Herren, Heather⁹  Jasti, Jamie⁴  Kudenchuk, Peter J.¹⁰  Scales, Damon C.^6,11  Stub, Dion^12,13  Richardson, Derek K.¹⁴  Zive, Dana M.^15,16 

[1] Univ Pittsburgh, Dept Crit Care Med, 3550 Terrace St, Pittsburgh, PA 15261 USA

[2] Univ Pittsburgh, Dept Emergency Med, Iroquois Bldg Suite 400A,3600 Forbes Ave, Pittsburgh, PA 15213 USA

[3] Univ Washington, Dept Biostat, F-600,Hlth Sci Bldg,NE Pacific St, Seattle, WA 98195 USA

[4] Med Coll Wisconsin, Dept Emergency Med, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA

[5] Univ Ottawa, Ottawa Hosp, Dept Emergency Med, Ottawa, ON, Canada

[6] Univ Toronto, Interdept Div Crit Care, Toronto, ON, Canada

[7] Univ Toronto, Dept Med, Toronto, ON, Canada

[8] Univ Hlth Network, Crit Care Med, 399 Bathurst St,Room 2MCL-411J,M5T-2S8, Toronto, ON, Canada

[9] Univ Washington, Resuscitat Outcome Consortium Clin Trial Ctr, 1107 NE 45th St,Suite 505, Seattle, WA 98105 USA

[10] Univ Washington, Dept Med, Div Cardiol, 1959 NE Pacific St, Seattle, WA 98195 USA

[11] Sunnybrook Hlth Sci Ctr, Dept Crit Care Med, 2075 Bayview Ave,Room D108, Toronto, ON M4N 3M5, Canada

[12] St Pauls Hosp, Vancouver, BC V6Z 1Y6, Canada

[13] Baker IDI Inst Heart & Diabet Inst, Melbourne, Vic, Australia

[14] Univ Calif San Francisco, Dept Emergency Med, 1001 Potrero Ave, San Francisco, CA 94110 USA

[15] Oregon Hlth & Sci Univ, Ctr Policy & Res Emergency Med, 3181 SW Sam Jackson Pk Rd,Mail Code CDW-EM, Portland, OR 97239 USA

[16] Associate Med Director Reg Paramed Program Easter, Toronto, ON, Canada

关键词: Cardiac arrest;    Prognostication;    Resuscitation;    Withdrawal of care;    Neurological prognosis;   

DOI  :  10.1016/j.resuscitation.2016.01.016

来源: Elsevier

【 摘 要 】

Background: Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after out-of-hospital cardiac arrest (OHCA). Although current guidelines recommend against WLST-N before 72 h (WLST-N < 72), this practice is common and may increase mortality. We sought to quantify these effects. Methods: In a secondary analysis of a multicenter OHCA trial, we evaluated survival to hospital discharge and survival with favorable functional status (modified Rankin Score <= 3) in adults alive >1 h after hospital admission. Propensity score modeling the probability of exposure to WLST-N < 72 based on pre-exposure covariates was used to match unexposed subjects with those exposed to WLST-N < 72. We determined the probability of survival and functionally favorable survival in the unexposed matched cohort, fit adjusted logistic regression models to predict outcomes in this group, and then used these models to predict outcomes in the exposed cohort. Combining these findings with current epidemiologic statistics we estimated mortality nationally that is associated with WLST-N < 72. Results: Of 16,875 OHCA subjects, 4265 (25%) met inclusion criteria. WLST-N < 72 occurred in one-third of subjects who died in-hospital. Adjusted analyses predicted that exposed subjects would have 26% survival and 16% functionally favorable survival if WLST-N < 72 did not occur. Extrapolated nationally, WLST-N < 72 may be associated with mortality in approximately 2300 Americans each year of whom nearly 1500 (64%) might have had functional recovery. Conclusions: After OHCA, death following WLST-N < 72 may be common and is potentially avoidable. Reducing WLST-N < 72 has national public health implications and may afford an opportunity to decrease mortality after OHCA. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

【 授权许可】

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