Abstract 13962: Predictors of Early Withdrawal of Care in Post-Cardiac Arrest Patients: Prejudice or Process?

Abstract

Background: In patients (pts) who are admitted following cardiac arrest, care is often withdrawn by families. Little is known of the timing or the factors that guide this decision.

Methods: We evaluated 170 survivors of out-of-hospital cardiac arrest (age 63 ± 16, 62.4% males) admitted from 2004 to 2010. Demographics and details of clinical care were analyzed. Analysis of variance was used to evaluate for statistical significance among three groups (early care withdrawal i.e. ≤72hrs, late withdrawal >72hrs and no care withdrawal). Univariate and multivariate logistic regression analyses were used for assessment of predictors of early (<72 hrs) care withdrawal. Data are reported as odds ratio and 95% CI.

Results: Of 170 pts with cardiac arrest, 32 had advanced directives (19%) and 90 pts had care withdrawn (53%). Of these 90 pts, 21 (23%) had prior directives. Mean time to care withdrawal was 2.5 days; however, 52 (52/90 58%) had care withdrawn within 72 hours. Pts with care withdrawal, either early or late, were more likely to be older, have advance directives, have a longer time to ROSC with a non VF rhythm, more use of epinephrine, and a poor Brainstem Reflex Score at 24 hours (all p <0.05). Using multivariate regression analysis, first family meeting and EEG done within 48 hours emerged as independent predictors of care withdrawal (OR=11.14 p=0.01 and OR=14.8 p=0.006 resp). Traditional factors favoring survival (Prior clinical status, Short ROSC, Shockable initial rhythm, Bystander CPR) did not impact the decision to withdraw care nor did the presence of advanced directives.

Conclusion: These results emphasize that in more than 50% of patients, care is withdrawn before the accepted time for neurological awakening (72 hrs) and appears to be substantially influenced by an early (<48hrs) family meeting and early EEG result. It is imperative that physicians be armed with accurate predictive tools if we are to avoid self fulfilling prophecies of poor survival following cardiac arrest.