Critical Care Explorations (Jul 2021)

Frequency of Withdrawal of Life-Sustaining Therapy for Perceived Poor Neurologic Prognosis

  • Alexis Steinberg, MD,
  • Benjamin S. Abella, MD, MPhil,
  • Emily J. Gilmore, MD,
  • David Y. Hwang, MD,
  • Niki Kennedy, BA,
  • Winnie Lau, MD,
  • Isabelle Mullen, BSc,
  • Nidhi Ravishankar, MD,
  • Charlotte F. Tisch, BA,
  • Adam Waddell, MD,
  • David J. Wallace, MD, MPH,
  • Qiang Zhang, BA,
  • Jonathan Elmer, MD, MSc

DOI
https://doi.org/10.1097/CCE.0000000000000487
Journal volume & issue
Vol. 3, no. 7
p. e0487

Abstract

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OBJECTIVES:. To measure the frequency of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis among decedents in hospitals of different sizes and teaching statuses. DESIGN:. We performed a multicenter, retrospective cohort study. SETTING:. Four large teaching hospitals, four affiliated small teaching hospitals, and nine affiliated nonteaching hospitals in the United States. PATIENTS:. We included a sample of all adult inpatient decedents between August 2017 and August 2019. MEASUREMENTS AND MAIN RESULTS:. We reviewed inpatient notes and categorized the immediately preceding circumstances as withdrawal of life-sustaining therapy for perceived poor neurologic prognosis, withdrawal of life-sustaining therapy for nonneurologic reasons, limitations or withholding of life support or resuscitation, cardiac death despite full treatment, or brain death. Of 2,100 patients, median age was 71 years (interquartile range, 60–81 yr), median hospital length of stay was 5 days (interquartile range, 2–11 d), and 1,326 (63%) were treated at four large teaching hospitals. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis occurred in 516 patients (25%) and was the sole contributing factor to death in 331 (15%). Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis was common in all hospitals: 30% of deaths at large teaching hospitals, 19% of deaths in small teaching hospitals, and 15% of deaths at nonteaching hospitals. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis happened frequently across all hospital units. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis contributed to one in 12 deaths in patients without a primary neurologic diagnosis. After accounting for patient and hospital characteristics, significant between-hospital variability in the odds of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis persisted. CONCLUSIONS:. A quarter of inpatient deaths in this cohort occurred after withdrawal of life-sustaining therapy for perceived poor neurologic prognosis. The rate of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis occurred commonly in all type of hospital settings. We observed significant unexplained variation in the odds of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis across participating hospitals.