External validation of a prognostic model predicting time of death after withdrawal of life support in neurocritical patients*

Abstract

The model discriminated well between patients who died within 60 mins after withdrawal of life support and those who did not. Further prospective validation is needed.

Time to Death after Terminal Withdrawal of Mechanical Ventilation: Specific Respiratory and Physiologic Parameters May Inform Physician Predictions

“…Comorbidities were based on identification of the condition in the We also noted performance of a spontaneous breathing trial within the 24 hours prior to withdrawal. For neurologic status, we abstracted the lowest Glasgow Coma Scale (GCS) score (range [2][3][4][5][6][7][8][9][10][11][12][13][14][15] 18 within the 24 hours prior to withdrawal. For hemodynamic status, we recorded the two lowest mean arterial pressure (MAP mmHg) values that were documented for >30 minutes during the 24 hours prior to ventilator discontinuation, then averaged those values for a final estimate.…”

“…[1][2][3] Discussions surrounding withdrawal of lifesustaining therapies often include family members of critically ill patients, and experts in end-of-life care recommend that these conversations address essential components of the dying process, including expected time to death. 4,5 Studies evaluating time to death after terminal withdrawal of lifesustaining measures in adults suggest that 45% to 76% of deaths occur within 60 minutes, [6][7][8][9][10][11][12][13] and the majority of patients die within 24 hours.…”

“…The majority of studies evaluating time to death after withdrawal of life-sustaining measures have assessed time to death as a dichotomous outcome (death within 60 minutes versus death occurring after this time). [6][7][8][9][10][11][12]15,16 Utilization of time to death in a continuous fashion may better identify independent predictors of time to death after withdrawal of life-sustaining measures. Improved predictive capability may enhance communication with family members about the dying process and thus improve end-of-life care for patients and their family members.…”

A few realistic questions raised by organ retrieval in the intensive care unit

“…Removal of the endotracheal tube (extubation) is more often associated with progression to organ donation than terminal weaning without extubation (12). Death within one or two hour(s) of withdrawal usually correlates with severe brain injuries (low Glasgow Coma Scale, absence of brainstem reflexes) (30)(31)(32)(35)(36)(37)(38), high dependence on mechanical ventilation (non-triggered mode, high FiO 2 , high positive expiratory pressure) (28-32,36,38,39), use of inotrope drugs (29,30,35,39), young age (28,35,40), underlying diseases (37,39), and physiological anomalies (high severity index scores, low blood pressure, low pH on arterial blood gas analysis) (37,38,40,41). Under Maastricht III conditions, the removal of organs must be scheduled before withholding/ withdrawal implementation and starts as soon as death is certified.…”

‘In plain language’: uniform criteria for organ donor recognition

“…For this reason, the recognition of potential circulatory death organ donors who will die in a short time after withdrawal of life support is of high interest for the transplantation community. A prediction model (DCD-N score) that has proved to be useful in retrospective and prospective analysis has been proposed by Yee et al [8][9][10] (Fig. 1).…”