title: Withdrawal of technological life support following subarachnoid hemorrhage.
abstract: BACKGROUND
  Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH.
  
  
  METHODS
  Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis.
  
  
  RESULTS
  The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160-1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022-1.068, p < 0.001) with the latter also impacting early WOLST decisions.
  
  
  CONCLUSIONS
  Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.
authors.affiliation: Department of Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA, rkowals1@jhmi.edu.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Kowalski
authors.forename: Tiffany R
authors.initials: TR
authors.lastname: Chang
authors.forename: J Ricardo
authors.initials: JR
authors.lastname: Carhuapoma
authors.forename: Rafael J
authors.initials: RJ
authors.lastname: Tamargo
authors.forename: Neeraj S
authors.initials: NS
authors.lastname: Naval
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D002532:Intracranial Aneurysm / Q000401:mortality / Q000628:therapy*; D008020:Life Support Care / Q000592:standards*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000401:mortality / Q000628:therapy*; D013997:Time Factors