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

Abstract

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 >1h 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, 4,265 (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 2,300 Americans each year of whom nearly 1,500 (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.

Delphi Analysis of Science Gaps in the 2015 American Heart Association Cardiac Arrest Guidelines

“…Using the method described by Elmer et al,26 we estimated the potential impact of addressing 3 of the identified themes that have been studied previously in out‐of‐hospital cardiac arrest (OHCA): telecommunicator CPR, improved neuroprognostication, and optimizing postarrest care (Table 3). Nationally, there are ≈167 000 emergency medical service–treated OHCAs in the United States, with a survival rate of ≈12% 1, 27.…”

“…Extrapolation conducted similar to that outlined in Elmer et al 26. CPR indicates cardiopulmonary resuscitation; CRC, cardiac receiving center; EMS, emergency medical service; OHCA, out‐of‐hospital cardiac arrest; T‐CPR, telecommunicator CPR; WLS, withdrawal of life support.…”

Out-of-hospital cardiac arrest: prehospital management

“…Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after OHCA. Although current guidelines recommend against withdrawing life-sustaining therapy before 72 hours, this practice is common and may increase mortality (77).…”

MicroRNAs as Potential Prognosticators of Neurological Outcome in Out-Of-Hospital Cardiac Arrest Patients

“…Many factors confound neurological prognostication postcardiac arrest including but not limited to the induction of therapeutic hypothermia, use of sedation and neuromuscular blockers and metabolic derangements caused by systemic ischemia. r Presumption of poor neurological outcome at less than 72 h lead to withdrawal of life-sustaining therapy, and may impact 2300 Americans annually, of whom 1500 may have had functional recovery [88]. r There is a need to develop reliable prognostic tools to support clinical decision-making in neurological outcomes after cardiac arrest.…”