title: Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest.
abstract: BACKGROUND
  Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after out-of-hospital cardiac arrest (OHCA). Although current guidelines recommend against WLST-N before 72h (WLST-N<72), this practice is common and may increase mortality. We sought to quantify these effects.
  
  
  METHODS
  In a secondary analysis of a multicenter OHCA trial, we evaluated survival to hospital discharge and survival with favorable functional status (modified Rankin Score ≤3) in adults alive >1h after hospital admission. Propensity score modeling the probability of exposure to WLST-N<72 based on pre-exposure covariates was used to match unexposed subjects with those exposed to WLST-N<72. We determined the probability of survival and functionally favorable survival in the unexposed matched cohort, fit adjusted logistic regression models to predict outcomes in this group, and then used these models to predict outcomes in the exposed cohort. Combining these findings with current epidemiologic statistics we estimated mortality nationally that is associated with WLST-N<72.
  
  
  RESULTS
  Of 16,875 OHCA subjects, 4265 (25%) met inclusion criteria. WLST-N<72 occurred in one-third of subjects who died in-hospital. Adjusted analyses predicted that exposed subjects would have 26% survival and 16% functionally favorable survival if WLST-N<72 did not occur. Extrapolated nationally, WLST-N<72 may be associated with mortality in approximately 2300 Americans each year of whom nearly 1500 (64%) might have had functional recovery.
  
  
  CONCLUSIONS
  After OHCA, death following WLST-N<72 may be common and is potentially avoidable. Reducing WLST-N<72 has national public health implications and may afford an opportunity to decrease mortality after OHCA.
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA; Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA. Electronic address: elmerjp@upmc.edu.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Elmer
authors.affiliation: Department of Biostatistics, University of Washington, F-600, Health Sciences Building, NE Pacific Street, Seattle, WA 98195, USA.
authors.forename: Cesar
authors.initials: C
authors.lastname: Torres
authors.affiliation: Department of Emergency Medicine, Medical College of Wisconsin, 9200W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
authors.forename: Tom P
authors.initials: TP
authors.lastname: Aufderheide
authors.affiliation: Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Associate Medical Director Regional Paramedic Program Eastern Ontario, Canada.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Austin
authors.affiliation: Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA.
authors.forename: Clifton W
authors.initials: CW
authors.lastname: Callaway
authors.affiliation: Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada; Critical Care Medicine, University Health Network, 399 Bathurst Street, Room 2MCL-411J, M5T-2S8, Toronto, ON, Canada.
authors.forename: Eyal
authors.initials: E
authors.lastname: Golan
authors.affiliation: Resuscitations Outcome Consortium Clinical Trial Center, University of Washington, 1107 NE 45th St., Suite 505, Seattle, WA 98105-4680, USA.
authors.forename: Heather
authors.initials: H
authors.lastname: Herren
authors.affiliation: Department of Emergency Medicine, Medical College of Wisconsin, 9200W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Jasti
authors.affiliation: Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-6422, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kudenchuk
authors.affiliation: Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON, Canada M4 N 3M5.
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
authors.affiliation: St Paul's Hospital, Vancouver, BC, Canada; Baker IDI Institute Heart and Diabetes Institute, Melbourne, Australia.
authors.forename: Dion
authors.initials: D
authors.lastname: Stub
authors.affiliation: Department of Emergency Medicine, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA.
authors.forename: Derek K
authors.initials: DK
authors.lastname: Richardson
authors.affiliation: Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code CDW-EM, Portland, OR 97239, USA.
authors.forename: Dana M
authors.initials: DM
authors.lastname: Zive
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000453:epidemiology* / Q000209:etiology; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications / Q000401:mortality / Q000628:therapy*; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D028761:Withholding Treatment
keywords: Cardiac arrest; Neurological prognosis; Prognostication; Resuscitation; Withdrawal of care
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