Alexis Steinberg1, Clifton W Callaway2, Robert M Arnold3, Tobias Cronberg4, Hiromichi Naito5, Koral Dadon6, Minjung Kathy Chae7, Jonathan Elmer8. 1. Department of Critical Care Medicine, Univsersity of Pittsburgh, Pittsburgh, PA, United States; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States. 2. Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States. 3. Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, United States. 4. Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden. 5. Department of Emergency, Critical Care, and Disaster Medicine, Okayama University, Okayama, Japan. 6. Technion Israel Institute of Technology, Haifa, Israel. 7. Department of Emergency Medicine, Ajou University Medical Center, Republic of Korea. 8. Department of Critical Care Medicine, Univsersity of Pittsburgh, Pittsburgh, PA, United States; Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States. Electronic address: elmerjp@upmc.edu.
Abstract
AIM: We explored preferences for prognostic test performance characteristics and error tolerance in decisions regarding withdrawal or continuation of life-sustaining therapy (LST) after cardiac arrest in a diverse cohort of medical providers. METHODOLOGY: We distributed a survey through professional societies and research networks. We asked demographic characteristics, preferences for prognostic test performance characteristics and views on acceptable false positive rates for decisions about LST after cardiac arrest. RESULTS: Overall, 640 respondents participated in our survey. Most respondents were attending physicians (74%) with >10 years of experience (59%) and practiced at academic centers (77%). Common specialties were neurology (22%), neuro- or general critical care (24%) and palliative care (31%). The majority (56%) felt an acceptable FPR for withdrawal of LST from patients who might otherwise have recovered was ≤0.1%. Acceptable FPRs for continuing LST in patients with unrecognized irrecoverable injury was higher, with 59% choosing a threshold ≤1%. Compared to providers with >10 years of experience, those with <5 years thought lower FPRs were acceptable (P < 0.001 for both). Palliative care providers accepted significantly higher FPRs for withdrawal of LST (P < 0.0001), and critical care providers accepted significantly higher FPRs for provision of long-term LST (P = 0.02). With regard to test performance characteristics, providers favored accuracy over timeliness, and prefer tests be optimized to predictrather than favorable outcomes. CONCLUSION: Medical providers are comfortable with low acceptable FPR for withdrawal (≤0.1%) and continuation (≤1%) of LST after cardiac arrest. These FPRs may be lower than can be achieved with current prognostic modalities.
AIM: We explored preferences for prognostic test performance characteristics and error tolerance in decisions regarding withdrawal or continuation of life-sustaining therapy (LST) after cardiac arrest in a diverse cohort of medical providers. METHODOLOGY: We distributed a survey through professional societies and research networks. We asked demographic characteristics, preferences for prognostic test performance characteristics and views on acceptable false positive rates for decisions about LST after cardiac arrest. RESULTS: Overall, 640 respondents participated in our survey. Most respondents were attending physicians (74%) with >10 years of experience (59%) and practiced at academic centers (77%). Common specialties were neurology (22%), neuro- or general critical care (24%) and palliative care (31%). The majority (56%) felt an acceptable FPR for withdrawal of LST from patients who might otherwise have recovered was ≤0.1%. Acceptable FPRs for continuing LST in patients with unrecognized irrecoverable injury was higher, with 59% choosing a threshold ≤1%. Compared to providers with >10 years of experience, those with <5 years thought lower FPRs were acceptable (P < 0.001 for both). Palliative care providers accepted significantly higher FPRs for withdrawal of LST (P < 0.0001), and critical care providers accepted significantly higher FPRs for provision of long-term LST (P = 0.02). With regard to test performance characteristics, providers favored accuracy over timeliness, and prefer tests be optimized to predictrather than favorable outcomes. CONCLUSION: Medical providers are comfortable with low acceptable FPR for withdrawal (≤0.1%) and continuation (≤1%) of LST after cardiac arrest. These FPRs may be lower than can be achieved with current prognostic modalities.
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