Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness
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). Patients with ICH were included across 121 Florida hospitals participating in th...
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| Veröffentlicht in: | Stroke (1970) 2021-12, Vol.52 (12), p.3891-3898 |
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| creator | Alkhachroum, Ayham Bustillo, Antonio J. Asdaghi, Negar Marulanda-Londono, Erika Gutierrez, Carolina M. Samano, Daniel Sobczak, Evie Foster, Dianne Kottapally, Mohan Merenda, Amedeo Koch, Sebastian Romano, Jose G. O’Phelan, Kristine Claassen, Jan Sacco, Ralph L. Rundek, Tatjana |
| description | 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).
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.
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], |
| doi_str_mv | 10.1161/STROKEAHA.121.035233 |
| format | Article |
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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.
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],
<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4],
<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229],
<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.
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.</description><identifier>ISSN: 0039-2499</identifier><identifier>EISSN: 1524-4628</identifier><identifier>DOI: 10.1161/STROKEAHA.121.035233</identifier><identifier>PMID: 34583530</identifier><language>eng</language><publisher>United States: Lippincott Williams & Wilkins</publisher><subject>Aged ; Cerebral Hemorrhage - complications ; Cerebral Hemorrhage - mortality ; Consciousness Disorders - etiology ; Female ; Hospital Mortality ; Humans ; Length of Stay ; Male ; Middle Aged ; Patient Discharge ; Recovery of Function ; Registries ; Resuscitation Orders ; Withholding Treatment - trends</subject><ispartof>Stroke (1970), 2021-12, Vol.52 (12), p.3891-3898</ispartof><rights>Lippincott Williams & Wilkins</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3988-e4332c899be3bf971608adbc86a8fb6a73156cfd1a75ef69852fce5f6520f493</citedby><cites>FETCH-LOGICAL-c3988-e4332c899be3bf971608adbc86a8fb6a73156cfd1a75ef69852fce5f6520f493</cites><orcidid>0000-0003-0670-2647 ; 0000-0003-0352-5913</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,776,780,3673,27903,27904</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/34583530$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Alkhachroum, Ayham</creatorcontrib><creatorcontrib>Bustillo, Antonio J.</creatorcontrib><creatorcontrib>Asdaghi, Negar</creatorcontrib><creatorcontrib>Marulanda-Londono, Erika</creatorcontrib><creatorcontrib>Gutierrez, Carolina M.</creatorcontrib><creatorcontrib>Samano, Daniel</creatorcontrib><creatorcontrib>Sobczak, Evie</creatorcontrib><creatorcontrib>Foster, Dianne</creatorcontrib><creatorcontrib>Kottapally, Mohan</creatorcontrib><creatorcontrib>Merenda, Amedeo</creatorcontrib><creatorcontrib>Koch, Sebastian</creatorcontrib><creatorcontrib>Romano, Jose G.</creatorcontrib><creatorcontrib>O’Phelan, Kristine</creatorcontrib><creatorcontrib>Claassen, Jan</creatorcontrib><creatorcontrib>Sacco, Ralph L.</creatorcontrib><creatorcontrib>Rundek, Tatjana</creatorcontrib><title>Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness</title><title>Stroke (1970)</title><addtitle>Stroke</addtitle><description>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).
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.
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],
<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4],
<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229],
<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.
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.</description><subject>Aged</subject><subject>Cerebral Hemorrhage - complications</subject><subject>Cerebral Hemorrhage - mortality</subject><subject>Consciousness Disorders - etiology</subject><subject>Female</subject><subject>Hospital Mortality</subject><subject>Humans</subject><subject>Length of Stay</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Patient Discharge</subject><subject>Recovery of Function</subject><subject>Registries</subject><subject>Resuscitation Orders</subject><subject>Withholding Treatment - trends</subject><issn>0039-2499</issn><issn>1524-4628</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNpFkU1vEzEQhi0EomnhHyDkI5cN_lh77WMUFVI1VRGNxNHyeseNYT-C7VXUGz8dVwnlMBqN3pl3Rs8g9IGSJaWSfn7Yfb-_vV5tVkvK6JJwwTh_hRZUsLqqJVOv0YIQritWa32BLlP6SQhhXIm36ILXQnHByQL9-RHyvov2aHs8ebwNHqqHOWUbxjA-4l0EmwcYM76DLtgMCd9NMds-5CccRvzN5lDUhJ9t8M2Yo3UQoY3FbgPDFOPePsJZHQ42ROjwehqTC9OcRkjpHXrjbZ_g_Tlfod2X6916U23vv96sV9vKca1UBTXnzCmtW-Ct1w2VRNmudUpa5VtpG06FdL6jthHgpVaCeQfCS8GIrzW_Qp9Otoc4_Z4hZTOE5KDv7QjlEsNE0zS8cCGltT61ujilFMGbQwyDjU-GEvOM3rygNwW9OaEvYx_PG-Z2gO5l6B_r_77Hqc8Q069-PkI0e7B93pvyHNLIhlSMMEpZqaoSVPG_ArySNQ</recordid><startdate>20211201</startdate><enddate>20211201</enddate><creator>Alkhachroum, Ayham</creator><creator>Bustillo, Antonio J.</creator><creator>Asdaghi, Negar</creator><creator>Marulanda-Londono, Erika</creator><creator>Gutierrez, Carolina M.</creator><creator>Samano, Daniel</creator><creator>Sobczak, Evie</creator><creator>Foster, Dianne</creator><creator>Kottapally, Mohan</creator><creator>Merenda, Amedeo</creator><creator>Koch, Sebastian</creator><creator>Romano, Jose G.</creator><creator>O’Phelan, Kristine</creator><creator>Claassen, Jan</creator><creator>Sacco, Ralph L.</creator><creator>Rundek, Tatjana</creator><general>Lippincott Williams & Wilkins</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0003-0670-2647</orcidid><orcidid>https://orcid.org/0000-0003-0352-5913</orcidid></search><sort><creationdate>20211201</creationdate><title>Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness</title><author>Alkhachroum, Ayham ; Bustillo, Antonio J. ; Asdaghi, Negar ; Marulanda-Londono, Erika ; Gutierrez, Carolina M. ; Samano, Daniel ; Sobczak, Evie ; Foster, Dianne ; Kottapally, Mohan ; Merenda, Amedeo ; Koch, Sebastian ; Romano, Jose G. ; O’Phelan, Kristine ; Claassen, Jan ; Sacco, Ralph L. ; Rundek, Tatjana</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3988-e4332c899be3bf971608adbc86a8fb6a73156cfd1a75ef69852fce5f6520f493</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Aged</topic><topic>Cerebral Hemorrhage - complications</topic><topic>Cerebral Hemorrhage - mortality</topic><topic>Consciousness Disorders - etiology</topic><topic>Female</topic><topic>Hospital Mortality</topic><topic>Humans</topic><topic>Length of Stay</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Patient Discharge</topic><topic>Recovery of Function</topic><topic>Registries</topic><topic>Resuscitation Orders</topic><topic>Withholding Treatment - trends</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Alkhachroum, Ayham</creatorcontrib><creatorcontrib>Bustillo, Antonio J.</creatorcontrib><creatorcontrib>Asdaghi, Negar</creatorcontrib><creatorcontrib>Marulanda-Londono, Erika</creatorcontrib><creatorcontrib>Gutierrez, Carolina M.</creatorcontrib><creatorcontrib>Samano, Daniel</creatorcontrib><creatorcontrib>Sobczak, Evie</creatorcontrib><creatorcontrib>Foster, Dianne</creatorcontrib><creatorcontrib>Kottapally, Mohan</creatorcontrib><creatorcontrib>Merenda, Amedeo</creatorcontrib><creatorcontrib>Koch, Sebastian</creatorcontrib><creatorcontrib>Romano, Jose G.</creatorcontrib><creatorcontrib>O’Phelan, Kristine</creatorcontrib><creatorcontrib>Claassen, Jan</creatorcontrib><creatorcontrib>Sacco, Ralph L.</creatorcontrib><creatorcontrib>Rundek, Tatjana</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Stroke (1970)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Alkhachroum, Ayham</au><au>Bustillo, Antonio J.</au><au>Asdaghi, Negar</au><au>Marulanda-Londono, Erika</au><au>Gutierrez, Carolina M.</au><au>Samano, Daniel</au><au>Sobczak, Evie</au><au>Foster, Dianne</au><au>Kottapally, Mohan</au><au>Merenda, Amedeo</au><au>Koch, Sebastian</au><au>Romano, Jose G.</au><au>O’Phelan, Kristine</au><au>Claassen, Jan</au><au>Sacco, Ralph L.</au><au>Rundek, Tatjana</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness</atitle><jtitle>Stroke (1970)</jtitle><addtitle>Stroke</addtitle><date>2021-12-01</date><risdate>2021</risdate><volume>52</volume><issue>12</issue><spage>3891</spage><epage>3898</epage><pages>3891-3898</pages><issn>0039-2499</issn><eissn>1524-4628</eissn><abstract>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).
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.
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],
<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4],
<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229],
<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.
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.</abstract><cop>United States</cop><pub>Lippincott Williams & Wilkins</pub><pmid>34583530</pmid><doi>10.1161/STROKEAHA.121.035233</doi><tpages>8</tpages><orcidid>https://orcid.org/0000-0003-0670-2647</orcidid><orcidid>https://orcid.org/0000-0003-0352-5913</orcidid><oa>free_for_read</oa></addata></record> |
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| ispartof | Stroke (1970), 2021-12, Vol.52 (12), p.3891-3898 |
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| source | MEDLINE; American Heart Association Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; Journals@Ovid Complete; Alma/SFX Local Collection |
| subjects | Aged Cerebral Hemorrhage - complications Cerebral Hemorrhage - mortality Consciousness Disorders - etiology Female Hospital Mortality Humans Length of Stay Male Middle Aged Patient Discharge Recovery of Function Registries Resuscitation Orders Withholding Treatment - trends |
| title | Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness |
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