Elfassy Michael D, Gewarges Mena, Fan Steve, McLean Bianca, Tanaka Dustin, Bagga Amrita, Bennett Stephen A, Janusonis Isabella, Nadarajah Shamara, Osei-Yeboah Clara, Rosh Jeremy, Teitelbaum Daniel, Sklar Jaime C, Basuita Manpreet, Scales Damon C, Luk Adriana C, Dorian Paul
Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada.
Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
CJC Open. 2024 Nov 26;7(4):449-455. doi: 10.1016/j.cjco.2024.11.013. eCollection 2025 Apr.
Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Most patients get hypoxic brain injury, which often leads to the withdrawal of life-sustaining therapy (WLST) because of concerns of poor neurologic prognosis. This study describes the rates and reasons for WLST and identifies factors associated with early WLST, defined as occurring within 72 hours of admission.
We conducted a multicentered, retrospective cohort study of adult OHCA patients admitted to 3 large academic hospitals in Toronto from January 2012 to December 2019. Data were extracted from medical records and analyzed using descriptive statistics and cause-specific hazards regression models to identify factors associated with WLST and documented goals of care (GOC) discussions.
Among 264 patients (median age 66 years, 76.5% male), the in-hospital mortality rate was 62.1%. Of the nonsurvivors, 67.1% died following WLST (90% of cases because of concern of poor neurologic prognosis), with 50% of WLST occurring <72 hours from admission. Formal declaration of brain death only occurred 9.8% of the time. Older age significantly increased the risk of early WLST. GOC discussions were documented only 56.4% of the time in the overall cohort and significantly associated with WLST across all time periods.
This study highlights the high incidence of WLST, and specifically early WLST, in OHCA patients. GOC discussions are routinely undocumented and is associated with a higher likelihood of WLST. These findings underscore heterogeneity of practice, and the influence of GOC discussions in education and shared decision making.
院外心脏骤停（OHCA）是全球死亡的主要原因。大多数患者会发生缺氧性脑损伤，由于担心神经预后不良，这往往导致撤除维持生命治疗（WLST）。本研究描述了WLST的发生率和原因，并确定了与早期WLST相关的因素，早期WLST定义为入院后72小时内发生。
我们对2012年1月至2019年12月在多伦多3家大型学术医院收治的成年OHCA患者进行了一项多中心回顾性队列研究。数据从医疗记录中提取，并使用描述性统计和特定病因风险回归模型进行分析，以确定与WLST和记录在案的医疗照护目标（GOC）讨论相关的因素。
在264例患者（中位年龄66岁，76.5%为男性）中，院内死亡率为62.1%。在非幸存者中，67.1%在WLST后死亡（90%的病例是因为担心神经预后不良），其中50%的WLST发生在入院后<72小时。仅9.8%的时间出现脑死亡的正式宣告。年龄较大显著增加了早期WLST的风险。在整个队列中，仅56.4%的时间记录了GOC讨论，并且在所有时间段内均与WLST显著相关。
本研究强调了OHCA患者中WLST，特别是早期WLST的高发生率。GOC讨论通常未记录在案，并且与更高的WLST可能性相关。这些发现强调了实践的异质性，以及GOC讨论在教育和共同决策中的影响。
