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. 2021 Dec;52(12):3891-3898.
doi: 10.1161/STROKEAHA.121.035233. Epub 2021 Sep 29.

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

Ayham Alkhachroum  1   2 , Antonio J Bustillo  1   2 , Negar Asdaghi  1   2 , Erika Marulanda-Londono  1   2 , Carolina M Gutierrez  1   2 , Daniel Samano  1   2 , Evie Sobczak  1   2 , Dianne Foster  3 , Mohan Kottapally  1   2 , Amedeo Merenda  1   2 , Sebastian Koch  1   2 , Jose G Romano  1   2 , Kristine O'Phelan  1   2 , Jan Claassen  4 , Ralph L Sacco  1   2 , Tatjana Rundek  1   2
Affiliations

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

Ayham Alkhachroum et al. Stroke. 2021 Dec.

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.

Keywords: aphasia; cerebral hemorrhage; consciousness; length of stay; logistic models.

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Figures

Figure 1-
Figure 1-. Temporal trends from 2010 to 2019 for In-hospital Mortality and Withhold/Withdrawal of Life-Sustaining Treatment among ICH patients with and without impaired LOC at onset
Caption: Bar graph (blue) and line (orange) showing trends of mortality and withhold/withdrawal of life-sustaining treatment (WOLST) by level of consciousness on presentation in intracerebral hemorrhage patients between 2010 and 2019 using the Florida Stroke Registry. The red line shows early (day 0 and 1) WOLST. Although both 2010 and 2015 AHS/ASA guidelines recommend aggressive treatment and against early DNR, a decreased in early WOLST was observed after 2015 in patients with impaired LOC.
Figure 2-
Figure 2-. Withhold/Withdrawal of Life-Sustaining Treatment Mediates Mortality in Impaired Level of Consciousness Patients
Caption: Impaired level of consciousness on presentation is associated with increased mortality in intracerebral hemorrhage patients OR 3.7 (95% CI 3.1 – 4.3, P < .0001); adjusted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. The withhold/withdrawal of life-sustaining treatment largely mediates mortality (mediation effect 190 95% CI 152 – 229, P <.0001); adjusted for basic demographics.
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References

    1. Pinho J, Costa AS, Araújo JM, Amorim JM, Ferreira C. Intracerebral hemorrhage outcome: A comprehensive update. J Neurol Sci 2019;398:54–66 - PubMed
    1. Navarrete-Navarro P, Rivera-Fernández R, López-Mutuberría MT, Galindo I, Murillo F, Dominguez JM, et al. Outcome prediction in terms of functional disability and mortality at 1 year among icu-admitted severe stroke patients: A prospective epidemiological study in the south of the european union (evascan project, andalusia, spain). Intensive Care Med 2003;29:1237–1244 - PubMed
    1. Zahuranec DB, Brown DL, Lisabeth LD, Gonzales NR, Longwell PJ, Smith MA, et al. Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology 2007;68:1651–1657 - PubMed
    1. Zahuranec DB, Morgenstern LB, Sanchez BN, Resnicow K, White DB, Hemphill JC 3rd. Do-not-resuscitate orders and predictive models after intracerebral hemorrhage. Neurology 2010;75:626–633 - PMC - PubMed
    1. Wabl R, Williamson CA, Pandey AS, Rajajee V. Long-term and delayed functional recovery in patients with severe cerebrovascular and traumatic brain injury requiring tracheostomy. J Neurosurg 2018;131:114–121 - PubMed

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