Be careful out there.
http://www.alphagalileo.org/ViewItem.aspx?ItemId=127989&CultureCode=en
More than a third of patients who suffer a major bleeding in the
brain and have their life support withdrawn might have eventually
regained an acceptable level of functioning if life support had been
sustained, suggests a new study presented at the American Stroke
Association’s International Stroke Conference 2013.
In the United States, 10 percent of the estimated 795,000 strokes
each year are intracerebral hemorrhages (ICH). ICH is the most common
type of bleeding stroke and it occurs when a weakened blood vessel
inside the brain ruptures and leaks blood into surrounding brain tissue,
causing neurological damage.
The new study, initially encompassing 590 patients at a Seattle
hospital, was designed to see whether “self-fulfilling prognostic
pessimism,” might play a part in life-support decisions, said David
Tirschwell, M.D., M.Sc., lead author and co-director of the University
of Washington Stroke Center at Harborview, in Seattle.
Researchers identified 78 patients whose life support was withdrawn
and compared their outcomes with 78 similar patients who were not
removed from life support.
Researchers chose a disability rating of “moderately severe” or
better as an “acceptable outcome.” Moderately severe could mean patients
are unable to attend to their own bodily needs or be unable to walk
without assistance, Tirschwell said. He also acknowledged that
“acceptable outcome” is up to each individual’s perception and
preferences.
At hospital discharge, only 4 percent of matched patients whose life
support was withdrawn had an acceptable outcome, compared with 38
percent of the matches who did not have life support withdrawn —
suggesting 34 percent of the group whose support was withdrawn might
also have had an acceptable outcome if support had been sustained.
“Greater patience and less pessimism may be called for in making these life-and-death decisions,” he said.
For their analysis, the researchers created a “propensity score”
indicating the probability that a decision to withdraw life support
would be made for a given ICH patient. The propensity score was based on
a number of factors: age; functional status before the ICH; level of
consciousness; how much bleeding occurred; pre-existing hypertension;
diabetes; atrial fibrillation; first temperature measurement on the
patient; and whether the patient was intubated for breathing support.
The strongest predictors of life support withdrawal — and the factors
most crucial in the patient matching — were measures of the
hemorrhage’s severity, Tirschwell said.
“These results are yet another piece of evidence suggesting
healthcare providers may be overly pessimistic in their assessments of
these patients’ prognoses, leading families to choose withdrawal of life
support before the patient has had a chance to recover from their
stroke,” Tirschwell said.
Most decisions to withdraw life support are made by next of kin, in
consultation with other relatives and with doctors, in the first few
days of hospitalization after the ICH, he said. In that time frame, “it
would be unrealistic to think the patient has had a chance to attain any
measure of recovery,” he said.
While “moderately severe” disability represents far-from-ideal
capabilities, “the time of hospital discharge is likely only a couple of
weeks after the ICH and recovery is a months-long process, and some of
these patients — many even — might recover further,” he said.
Tirschwell said the conclusions are based on the assumption of
further recovery, which is known to be a long process and notoriously
difficult to predict and the fact that quality of life is subjective.
The study, conducted in one hospital, might not reflect practices at
other institutions, Tirschwell said.
“The study does a commendable job measuring the effect on patient
outcome of the decision-making process, probably the single most
difficult factor to model,” said Steven Greenberg, M.D., Ph.D., chair of
the International Stroke Conference, Harvard Medical School neurology
professor and director Hemorrhagic Stroke Research at Massachusetts
General Hospital in Boston.
“The finding that fully a third of ICH patients in whom life support
is withdrawn might otherwise survive is staggering” Greenberg said. “The
major challenges in interpreting this finding are to determine whether
patients can make further improvements after discharge, and if not,
whether needing someone to help with walking, washing and other needs is
an acceptable quality of life for them.”
Co-authors are Kyra J. Becker, M.D.; Claire J. Creutzfeldt, M.D.;
Marisa Gallo, B.S.; and W.T. Longstreth Jr., M.D., M.P.H. Author
disclosures are on the abstract.
Funding from the healthcare company Novo Nordisk supported the database used in the research.
Follow news from the ASA International Stroke Conference 2013 via Twitter @HeartNews; #ISC13.
Statements and conclusions of study authors that are presented at
American Stroke Association scientific meetings are solely those of the
study authors and do not necessarily reflect association policy or
position. The association makes no representation or warranty as to
their accuracy or reliability. The association receives funding
primarily from individuals; foundations and corporations (including
pharmaceutical, device manufacturers and other companies) also make
donations and fund specific association programs and events. The
association has strict policies to prevent these relationships from
influencing the science content. Revenues from pharmaceutical and
device corporations are available at www.heart.org/corporatefunding.
No comments:
Post a Comment