Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

Abstract

Background and Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3], P <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3–0.4], P <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152–229], P <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry

“…In addition to disease severity, we found that older age, level of consciousness, state region, white race, insurance status, ambulation status at baseline, and stroke center type are important factors contributing to the decision of WLST. Our results are consistent with prior publications regarding older age, baseline functional status, level of consciousness and race (10–13). The higher rates of WLST in comprehensive stroke centers may reflect a sicker population (with more comorbidities, and more severe strokes) than those in other center types.…”

“…Patient and family values and preference, self-fulfilling prophecy (driven by poor prognosis beliefs), and cognitive biases in prognosis shortly after injury may lead to the decision to withhold or withdraw of life-sustaining therapies (WLST) (6)(7)(8)(9). WLST is more commonly seen after ICH and SAH than AIS (9)(10)(11). Factors such as age, stroke severity, and impaired level of consciousness may influence WLST decisions (10)(11)(12)(13).…”

“…WLST is more commonly seen after ICH and SAH than AIS (9)(10)(11). Factors such as age, stroke severity, and impaired level of consciousness may influence WLST decisions (10)(11)(12)(13). The temporal trends and predictors of WLST decision during hospitalization are not well studied.…”

Predictors of do-not-attempt-resuscitation decisions in patients with infratentorial or large supratentorial intracerebral hemorrhages and consequences thereafter: a register-based, longitudinal study in Sweden

“…The majority of patients who died had low GCS scores at admission. Impaired level of consciousness has been associated with higher mortality, mediated through withdrawal of life sustaining treatment [ 20 ]. However, not all patients with DNAR decisions in our study received palliative care.…”

Treatment-Limiting Decisions in Patients with Spontaneous Intracerebral Hemorrhage

“…Unsurprisingly, such decisions can be enormously disruptive for both patients and their families. In cases where key stakeholders (i.e., patients if able vs. family) agree that further interventions would in fact be futile, treatment-limiting decisions (TLDs) may ultimately be implemented [ 5 ]. Clinicians not only shoulder the medical responsibility for implementing such TLDs, but often face additional time constraints in decision-making and providing support/guidance to patients/family members.…”