Friday, June 05, 2015

Factors leading to care withdrawal after resuscitation from cardiac arrest

From a recent study:


Data was collected from 189 survivors to hospital admission. Patients were classified by survival status upon hospital discharge, and those who died were categorized into withdrawal vs. no withdrawal of care. Those who had care withdrawn were further subdivided into early care withdrawal i.e. less then or equal to 72 h vs. late withdrawal greater than 72 h. Multivariable adjusted odds ratios were used to assess factors associated with early care withdrawal.


Of 189 patients with cardiac arrest, only 36 had advanced directives (19%) and 99 (52%) had care withdrawn. Most patients whose care was withdrawn died in hospital (94/99, 95%), and the remainder died in hospice. Care was withdrawn early less than or equal to 72 h in the majority of patients (59/94, 63%). Median time to early care withdrawal was 2 days IQR (1–3). Factors associated with early care withdrawal were age greater than or equal to 75 years, poor initial neurologic exam, multiple co morbidities, multi-organ failure, lactic acid greater than or equal to10 mmol L−1, Caucasian race and absence of bystander CPR. Advance directives did not appear to determine early care withdrawal.

Although most cardiac arrest patients do not have advance directives, care is often withdrawn in more than 50% and in many before the accepted time for neurological awakening (72 h). The decision to withdraw care is influenced by older age, race, preexisting co morbidities, multi-organ failure, and a poor initial neurological exam. Further studies are needed to better understand this phenomenon and other sociological factors that guide such decisions.

These findings are concerning. Basing care withdrawal on neurological findings before 72 hours is against current resuscitation research evidence. If age and comorbidities were factors one wonders why the patients were resuscitated in the first place.

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