Withdrawal of life support in critically ill neurosurgical patients and in-hospital death after discharge from the neurosurgical intensive care unit

Clinical article

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Object

The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI).

Methods

Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI.

Results

One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03–1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04–1.07), transfer from another hospital (OR 3.7, 95% CI 1.6–8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4–12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2–17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4–20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9–16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92–0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1–1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83–47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate.

Conclusions

The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI—including patient age and the severity and type of neurological injury—play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.

Abbreviations used in this paper: APACHE II = Acute Physiology and Chronic Health Evaluation II; CPR = cardiopulmonary resuscitation; DNR = do not resuscitate; ICH = intracerebral hemorrhage; ICU = intensive care unit; LOS = length of stay; NI = neurointensivist; NICU = neurosurgical ICU; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury; UHC = University Hospitals Consortium; WOLS = withdrawal of life support.

Article Information

Address correspondence to: Panayiotis N. Varelas, M.D., Ph.D., Department of Neurology and Neurosurgery, Henry Ford Hospital, K-11, 2799 West Grand Boulevard, Detroit, Michigan 48202. email: varelas@neuro.hfh.edu.

© AANS, except where prohibited by US copyright law.

Headings

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