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. 2023 Jun 23;5(7):e0934.
doi: 10.1097/CCE.0000000000000934. eCollection 2023 Jul.

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

Ayham Alkhachroum  1 , Lili Zhou  1 , Negar Asdaghi  1 , Hannah Gardener  1 , Hao Ying  1 , Carolina M Gutierrez  1 , Brian M Manolovitz  1 , Daniel Samano  1 , Danielle Bass  1 , Dianne Foster  2 , Nicole B Sur  1 , David Z Rose  3 , Angus Jameson  4 , Nina Massad  1 , Mohan Kottapally  1 , Amedeo Merenda  1 , Robert M Starke  5 , Kristine O'Phelan  1 , Jose G Romano  1 , Jan Claassen  6 , Ralph L Sacco  1 , Tatjana Rundek  1
Affiliations

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

Ayham Alkhachroum et al. Crit Care Explor. .

Abstract

Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined.

Design: Observational study (2008-2021).

Setting: Florida Stroke Registry (152 hospitals).

Patients: Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients.

Interventions: None.

Measurements and main results: Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable.

Conclusions: In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.

Keywords: intracerebral hemorrhage; ischemic stroke; subarachnoid hemorrhage; temporal trends; withdrawal of life-sustaining therapy.

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Conflict of interest statement

This work represents the author’s independent analysis of local or multicenter data gathered using the American Heart Association (AHA) Get With The Guidelines (GWTG) Patient Management Tool/IQVIA Registry Platform but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program. Dr. Alkhachroum is supported by an institutional KL2 Career Development Award from the Miami Clinical and Translational Science Institute (CTSI) National Center for Advancing Translational Sciences (NCATS) UL1TR002736 and by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (NIH) under Award Number K23NS126577 and R21NS128326. He is a junior editor for Journal of Clinical and Translational Science. Dr. Asdaghi is supported by salary support from the Florida Stroke Registry (FSR) COHAN-A1 R2 contract. Dr. Sur is supported by an institutional KL2 Career Development Award from the Miami CTSI NCATS KL2TR002737, the Florida Department of Health for work on the FSR. Dr. Sur serves as CME/Highlights Editor for journal Stroke and is on the editorial board for the Journal of the American College of Cardiology: Advances. Dr. Starke is supported by supported by the Neurosurgery Research & Education Foundation, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by the NIH (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami CTSI, from the NCATS and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Dr. Starke has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. Dr. Romano is supported by grant funding from the NIH R01 MD012467 and U24 NS107267. Dr. Claassen is supported by grant funding from the NIH R01 NS106014, R03 NS112760, R21 NS128326, and the Dana Foundation. Dr. Claassen is a minority shareholder at iCE Neurosystems. Dr. Sacco is funded by the Florida Department of Health for work on the FSR and by grants from the NIH (R01 NS029993, R01 MD012467, R01 NS040807, U10NS086528), and the NCATS (UL1 TR002736 and KL2 TR002737) and receives compensation from the AHA as Editor-In-Chief of Stroke. Dr. Rundek is funded by the Florida Department of Health for work on the FSR and by the grants from the NIH (R01 MD012467, R01 NS029993, R01 NS040807, and 1U24 NS107267), and the NCATS (UL1 TR002736 and KL2 TR002737). The remaining authors have not disclosed any potential conflicts of interest.

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