Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, New Haven, CT, 06510, USA.
Departments of Anesthesiology and Neurology, Duke University, Durham, USA.
Neurocrit Care. 2018 Dec;29(3):419-425. doi: 10.1007/s12028-018-0554-4.
Prior studies of patients in the intensive care unit have suggested racial/ethnic variation in end-of-life decision making. We sought to evaluate whether race/ethnicity modifies the implementation of comfort measures only status (CMOs) in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH).
We analyzed data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a prospective cohort study specifically designed to enroll equal numbers of white, black, and Hispanic subjects. ICH patients aged ≥ 18 years were enrolled in ERICH at 42 hospitals in the USA from 2010 to 2015. Univariate and multivariate logistic regression analyses were implemented to evaluate the association between race/ethnicity and CMOs after adjustment for potential confounders.
A total of 2705 ICH cases (912 black, 893 Hispanic, 900 white) were included in this study (mean age 62 [SD 14], female sex 1119 [41%]). CMOs patients comprised 276 (10%) of the entire cohort; of these, 64 (7%) were black, 79 (9%) Hispanic, and 133 (15%) white (univariate p < 0.001). In multivariate analysis, compared to whites, blacks were half as likely to be made CMOs (OR 0.50, 95% CI 0.34-0.75; p = 0.001), and no statistically significant difference was observed for Hispanics. All three racial/ethnic groups had similar mortality rates at discharge (whites 12%, blacks 9%, and Hispanics 10%; p = 0.108). Other factors independently associated with CMOs included age (p < 0.001), premorbid modified Rankin Scale (p < 0.001), dementia (p = 0.008), admission Glasgow Coma Scale (p = 0.009), hematoma volume (p < 0.001), intraventricular hematoma volume (p < 0.001), lobar (p = 0.032) and brainstem (p < 0.001) location and endotracheal intubation (p < 0.001).
In ICH, black patients are less likely than white patients to have CMOs. However, in-hospital mortality is similar across all racial/ethnic groups. Further investigation is warranted to better understand the causes and implications of racial disparities in CMO decisions.
先前对重症监护病房患者的研究表明，在临终决策方面存在种族/民族差异。我们试图评估种族/民族是否会改变自发性非创伤性颅内出血 (ICH) 患者的舒适措施仅状态 (CMO) 的实施。
我们分析了来自种族/民族颅内出血差异 (ERICH) 研究的数据，这是一项专门设计为纳入白人、黑人和西班牙裔患者人数相等的前瞻性队列研究。2010 年至 2015 年，美国 42 家医院纳入了年龄≥18 岁的自发性、非创伤性 ICH 患者。在调整潜在混杂因素后，采用单变量和多变量逻辑回归分析评估种族/民族与 CMO 之间的关联。
本研究共纳入 2705 例 ICH 病例（912 例黑人、893 例西班牙裔、900 例白人）（平均年龄 62[14]岁，女性 1119[41%]）。CMO 患者占整个队列的 276 例（10%）；其中，黑人 64 例（7%），西班牙裔 79 例（9%），白人 133 例（15%）（单变量 p<0.001）。多变量分析显示，与白人相比，黑人成为 CMO 的可能性减半（OR 0.50，95%CI 0.34-0.75；p=0.001），而西班牙裔没有统计学差异。三个种族/民族的出院时死亡率相似（白人 12%，黑人 9%，西班牙裔 10%；p=0.108）。其他与 CMO 独立相关的因素包括年龄（p<0.001）、发病前改良 Rankin 量表评分（p<0.001）、痴呆症（p=0.008）、入院格拉斯哥昏迷量表评分（p=0.009）、血肿体积（p<0.001）、脑室内血肿体积（p<0.001）、叶（p=0.032）和脑干（p<0.001）部位和气管插管（p<0.001）。
在 ICH 中，黑人患者比白人患者更不可能接受 CMO。然而，所有种族/民族的住院死亡率相似。需要进一步研究以更好地了解 CMO 决策中种族差异的原因和影响。
