Abstract
Introduction
Neurologists are often asked to define prognosis in comatose patients. However, comatose patients following cardiac arrest are usually cared for by cardiologists or intensivists, and it is their approach that will influence decisions regarding withdrawal of life-sustaining interventions (WLSI). We observed that factors leading to these decisions vary across specialties and considered whether they could result in self-fulfilling prophecies and early WLSI. We conducted a hypothesis-generating qualitative study to identify factors used by non-neurologists to define prognosis in these patients and construct an explanatory model for how early WLSI might occur.
Methods
This was a single-center qualitative study of intensivists caring for cardiac arrest patients with hypoxic-ischemic coma. Thirty attending physicians (n = 16) and fellows (n = 14) from cardiac (n = 8), medical (n = 6), surgical (n = 10), and neuro (n = 6) intensive care units underwent semi-structured interviews. Interview transcripts were analyzed using grounded theory techniques.
Results
We found three components of early WLSI among non-neurointensivists: (1) development of fixed negative opinions; (2) early framing of poor clinical pictures to families; and (3) shortened windows for judging recovery potential. In contrast to neurointensivists, non-neurointensivists’ negative opinions were frequently driven by patients’ lack of consciousness and cardiopulmonary resuscitation circumstances. Both groups were influenced by age and comorbidities.
Conclusions
The results demonstrate that factors influencing prognostication differ across specialties. Some differ from those recommended by published guidelines and may lead to self-fulfilling prophecies and early WLSI. Better understanding of this framework would facilitate educational interventions to mitigate this phenomenon and its implications on patient care.
Similar content being viewed by others
References
Levy DE, Caronna JJ, Singer BH, et al. Predicting outcome from hypoxic-ischemic coma. JAMA. 1985;253:1420–6.
Wijdicks EF, Hijdra A, Young GB, et al. Quality Standards Subcommittee of the American Academy of N. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology. Neurology. 2006;67:203–10.
Nolan JP, Soar J, Zideman DA, et al. European resuscitation council guidelines for resuscitation 2010 section 1. Executive summary. Resuscitation. 2010;81:1219–76.
Sandroni C, Cariou A, Cavallaro F, et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the european resuscitation council and the european society of intensive care medicine. Intensive Care Med. 2014;40:1816–31.
Cook D, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349:1123–32.
Kowalski RG, Chang TR, Carhuapoma JR, et al. Withdrawal of technological life support following subarachnoid hemorrhage. Neurocrit Care. 2013;19:269–75.
Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56:766–72.
Rocker G, Cook D, Sjokvist P, et al. Clinician predictions of intensive care unit mortality. Crit Care Med. 2004;32:1149–54.
Weimer JM, Nowacki AS, Frontera JA. Withdrawal of life-sustaining therapy in patients with intracranial haemorrhage: self-fulfilling prophecy or accurate prediction of outcome? Critical Care Medicine. 2016. Jan 20 [Epub ahead of print].
Frick S, Uehlinger DE, Zenklusen RMZ. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors—a prospective comparative study. Crit Care Med. 2003;31:456–61.
Christensen C, Cottrell JJ, Murakami J, et al. Forecasting survival in the medical intensive care unit: a comparison of clinical prognoses with formal estimates. Methods Inf Med. 1993;32:302–8.
Morgenstern LB, Zahuranec DB, Sanchez Brisa N, et al. Full medical support for intracerebral hemorrhage. Neurology. 2015;84:1739–44.
Izzy S, Compton R, Carandang R, et al. Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury too? Neurocrit Care. 2013;19:347–63.
Verkade MA, Nieuwenhoff MD, Kompanje EJO. Withdrawal of life-sustaining treatment in a mixed intensive care unit: most common in patients with catastrophic brain injury. Neurocrit Care. 2012;16:130135.
Greer DM, Rosenthal ES, Wu O. Neuroprognostication of hypoxic-ischaemic coma in the therapeutic hypothermia era. Nat Rev Neurol. 2014;10:190–203.
Geocadin RG, Peberdy MA, Lazar RM. Poor survival after cardiac arrest resuscitation: a self-fulfilling prophecy or biologic destiny? Crit Care Med. 2012;40:979–80.
Sandroni C, Geocadin RG. Neurological prognostication after cardiac arrest. Curr Opin Crit Care. 2015;21:209–14.
Pistoia F, Sacco S, Stewart JE, et al. Postanoxic vegetative state: avoiding the self-fulfilling prophecy. Neurohospitalist. 2015;5:7.
Fugate JE, Wijdicks EF, Mandrekar J, et al. Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol. 2010;68:907–14.
Hemphill JC 3rd. Do-not-resuscitate orders, unintended consequences, and the ripple effect. Crit Care. 2007;11:121.
Racine E, Dion MJ, Wijman CA, et al. Profiles of neurological outcome prediction among intensivists. Neurocrit Care. 2009;11:345–52.
Wilson ME, Rhudy LM, Ballinger BA, et al. Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study. Intensive Care Med. 2013;39:1009–18.
Sprung CL, Cohen SL, Sjokvist P, et al. End of life practices in european intensive care units: the ethicus study. JAMA. 2003;290:790–7.
Hemphill JC 3rd, White DB. Clinical nihilism in neuroemergencies. Emerg Med Clin N Am. 2009;27:27–37.
Albaeni A, Chandra-Strobos N, Vaidya D, et al. Predictors of early care withdrawal following out-of-hospital cardiac arrest. Resuscitation. 2014;85:1455–61.
Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995;18(2):179–83.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57.
Kennedy TJ, Lingard LA. Making sense of grounded theory in medical education. Med Educ. 2006;40:101–8.
Warters B. Review of tams analyzer. Field Methods. 2005;17:321–8.
Zier LS, Burack JH, Micco G, et al. Doubt and belief in physicians’ ability to prognosticate during critical illness: the perspective of surrogate decision makers. Crit Care Med. 2008;36:2341–7.
Christakis NA, Iwashyna TJ. Attitude and self-reported practice regarding prognostication in a national sample of internists. Arch Intern Med. 1998;158:2389–95.
Meadow W, Pohlman A, Frain L, et al. Power and limitations of daily prognostications of death in the medical intensive care unit. Crit Care Med. 2011;39:474–9.
Mulder M, Gibbs HG, Smith SW, et al. Awakening and withdrawal of life-sustaining treatment in cardiac arrest survivors treated with therapeutic hypothermia. Crit Care Med. 2014;42:2493–9.
Callaway CW, Schmicker RH, Brown SP, et al. Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest. Resuscitation. 2014;85:657–63.
Zandbergen EG, Hijdra A, Koelman JH, et al. Prediction of poor outcome within the first 3 days of postanoxic coma. Neurology. 2006;66:62–8.
Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. 2015;41:1572–85.
Rogove HJ, Safar P, Sutton-Tyrrell K, Abramson NS. Old age does not negate good cerebral outcome after cardiopulmonary resuscitation: analyses from the brain resuscitation clinical trials. The brain resuscitation clinical trial i and ii study groups. Crit Care Med. 1995;23:18–25.
Winther-Jensen M, Kjaergaard J, Hassager C, et al. Resuscitation and post resuscitation care of the very old after out-of-hospital cardiac arrest is worthwhile. Int J Cardiol. 2015;201:616–23.
Chan PS, Spertus JA, Krumholz HM, et al. A validated prediction tool for initial survivors of in-hospital cardiac arrest. Arch Intern Med. 2012;172:947–53.
Lopez-Rolon A, Bender A, Project HIG. Hypoxia and outcome prediction in early-stage coma (project hope): an observational prospective cohort study. BMC Neurol. 2015;15:82.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Ong, C.J., Dhand, A. & Diringer, M.N. Early Withdrawal Decision-Making in Patients with Coma After Cardiac Arrest: A Qualitative Study of Intensive Care Clinicians. Neurocrit Care 25, 258–265 (2016). https://doi.org/10.1007/s12028-016-0275-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12028-016-0275-5