Nicolas Nesseler1, Antoine Roquilly, Sigismond Lasocki, Claire Dahyot-Fizelier, Yoann Launey, Cinotti Raphaël, Marine Hubert, Sonia Isslame, Pierre-François Perrigault, Thomas Geeraerts, Olivier Mimoz, Fouad Marhar, Yannick Mallédant, Fanny Feuillet, Karim Asehnoune, Philippe Seguin. 1. From the Intensive Care Unit, Anesthesia and Critical Care Department, Pontchaillou, University Hospital of Rennes (NN, YL, MH, SI, YM, PS), Inserm, UMR 1214 NuMeCan, Hôpital Pontchaillou (NN, YL, YM, PS), Université Rennes 1, Faculté de Médecine, Rennes Cedex (NN, YL, YM, PS), Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu - HME, University Hospital of Nantes, Nantes (AR, RC, KA), Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Angers, Angers (SL), Neuro-Intensive Care Unit, Anesthesia and Critical Care Department, Poitiers, University Hospital of Poitiers, Poitiers (CD-F), Intensive Care Unit, Anesthesia and Critical Care Department, Gui de Chauliac University Hospital of Montpellier, Montpellier (P-FP), Department of Anesthesiology and Critical Care, University Hospital of Toulouse, Toulouse (TG, FM), Surgical Intensive Care Unit, Anesthesia and Critical Care Department, Poitiers, University Hospital of Poitiers, Poitiers (OM), EA 4275 SPHERE 'MethodS for Patients-centered outcomes and HEalth REsearch', UFR des Sciences Pharmaceutiques, Nantes University (FF), Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital Nantes, Nantes, France (FF).
Abstract
BACKGROUND: Knowledge of the factors associated with the decision to withdraw or withhold life support (WWLS) in brain-injured patients is limited. However, most deaths in these patients may involve such a decision. OBJECTIVES: To identify factors associated with the decision to WWLS in brain-injured patients requiring mechanical ventilation who survive the first 24 h in the ICU, and to analyse the outcomes and time to death. DESIGN: A retrospective observational multicentre study. SETTINGS: Twenty French ICUs in 18 university hospitals. PATIENTS: A total of 793 mechanically ventilated brain-injured adult patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Decision to WWLS within 3 months of ICU admission, and death or Glasgow Outcome Scale (GOS) score at day 90. RESULTS: A decision to WWLS was made in 171 patients (22%), of whom 89% were dead at day 90. Out of the 247 deaths recorded at day 90, 153 (62%) were observed after a decision to WWLS. The median time between admission and death when a decision to WWLS was made was 10 (5 to 20) days vs. 10 (5 to 26) days when no end-of-life decision was made (P < 0.924). Among the 18 patients with a decision to WWLS who were still alive at day 90, three patients (2%) had a GOS score of 2, nine patients (5%) had a GOS score of 3 and five patients (3%) a GOS score of 4. Older age, presence of one nonreactive and dilated pupil, Glasgow Coma Scale less than 7, barbiturate use, acute respiratory distress syndrome and worsening lesions on computed tomography scans were each independently associated with decisions to WWLS. CONCLUSION: Using a nationwide cohort of brain-injured patients, we observed a high proportion of deaths associated with an end-of-life decision. Older age and several disease severity factors were associated with the decision to WWLS.
BACKGROUND: Knowledge of the factors associated with the decision to withdraw or withhold life support (WWLS) in brain-injured patients is limited. However, most deaths in these patients may involve such a decision. OBJECTIVES: To identify factors associated with the decision to WWLS in brain-injured patients requiring mechanical ventilation who survive the first 24 h in the ICU, and to analyse the outcomes and time to death. DESIGN: A retrospective observational multicentre study. SETTINGS: Twenty French ICUs in 18 university hospitals. PATIENTS: A total of 793 mechanically ventilated brain-injured adult patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Decision to WWLS within 3 months of ICU admission, and death or Glasgow Outcome Scale (GOS) score at day 90. RESULTS: A decision to WWLS was made in 171 patients (22%), of whom 89% were dead at day 90. Out of the 247 deaths recorded at day 90, 153 (62%) were observed after a decision to WWLS. The median time between admission and death when a decision to WWLS was made was 10 (5 to 20) days vs. 10 (5 to 26) days when no end-of-life decision was made (P < 0.924). Among the 18 patients with a decision to WWLS who were still alive at day 90, three patients (2%) had a GOS score of 2, nine patients (5%) had a GOS score of 3 and five patients (3%) a GOS score of 4. Older age, presence of one nonreactive and dilated pupil, Glasgow Coma Scale less than 7, barbiturate use, acute respiratory distress syndrome and worsening lesions on computed tomography scans were each independently associated with decisions to WWLS. CONCLUSION: Using a nationwide cohort of brain-injured patients, we observed a high proportion of deaths associated with an end-of-life decision. Older age and several disease severity factors were associated with the decision to WWLS.
Authors: Ernest van Veen; Mathieu van der Jagt; Giuseppe Citerio; Nino Stocchetti; Diederik Gommers; Alex Burdorf; David K Menon; Andrew I R Maas; Erwin J O Kompanje; Hester F Lingsma Journal: Intensive Care Med Date: 2021-08-05 Impact factor: 17.440