Su Min-I, Hsiao Chia-Ying, Ma Jui-Chu, Chang Che-Ming
Department of Medicine, MacKay Medical College, New Taipei, Taiwan.
Department of Internal Medicine, Division of Cardiology, Taitung MacKay Memorial Hospital, Taitung, Taiwan.
Palliat Med Rep. 2025 Jun 4;6(1):324-332. doi: 10.1089/pmr.2025.0015. eCollection 2025.
Aneurysmal subarachnoid hemorrhage (aSAH) carries high mortality rates and often requires critical family decisions about code status when complications occur. The American Heart Association provides treatment guidelines but acknowledges a significant knowledge gap regarding do-not-resuscitate or do-not-intubate (DNR/DNI) decisions in patients with aSAH, challenging clinicians in identifying appropriate timing for these discussions.
To identify demographic and clinical physiological factors associated with code status transition in adults with aSAH admitted to the intensive care unit, supporting value-based decision making through more informed and timely discussions between health care providers and families that align with patients' core values and preferences.
Retrospective cohort study analyzing Medical Information Mart for Intensive Care IV database (2008-2022) data from 731 patients with aSAH. Researchers collected demographics, vital signs, laboratory tests, disease severity scores, and code status transition, performing univariate and multivariate Cox regression analyses to identify significant predictors.
Among patients initially with full-code status, 25.8% transitioned to DNR/DNI during hospitalization. Multivariate analysis identified four independent predictors: advanced age (hazard ratio [HR] = 1.024), lower mean blood pressure (HR = 0.987), higher simplified acute physiology score II (SAPS II) score (HR = 1.018, each one-point increase raises transition risk by 1.8%), and hospice services (HR = 6.951). Patients with code status limitations received less invasive therapy, more hospice services, and had higher mortality rates.
Age, blood pressure, SAPS II, and hospice services predict code status transitions in patients with aSAH. Identifying high-risk patients enables timely code status discussions, ensuring treatment aligns with patient values and improving family decision making during critical situations.
动脉瘤性蛛网膜下腔出血（aSAH）死亡率高，并发症出现时通常需要家属就抢救状态做出关键决定。美国心脏协会提供了治疗指南，但承认在aSAH患者的不复苏或不插管（DNR/DNI）决定方面存在重大知识空白，这给临床医生确定这些讨论的合适时机带来了挑战。
确定入住重症监护病房的成年aSAH患者中与抢救状态转变相关的人口统计学和临床生理因素，通过医疗服务提供者与家属之间更明智、及时的讨论，支持基于价值的决策，这些讨论要符合患者的核心价值观和偏好。
回顾性队列研究，分析重症监护医学信息集市IV数据库（2008 - 2022年）中731例aSAH患者的数据。研究人员收集了人口统计学、生命体征、实验室检查、疾病严重程度评分和抢救状态转变情况，进行单因素和多因素Cox回归分析以确定显著预测因素。
在最初处于完全抢救状态的患者中，25.8%在住院期间转变为DNR/DNI。多因素分析确定了四个独立预测因素：高龄（风险比[HR]=1.024）、较低的平均血压（HR = 0.987）、较高的简化急性生理学评分II（SAPS II）（HR = 1.018，每增加一分，转变风险增加1.8%）以及临终关怀服务（HR = 6.951）。抢救状态受限的患者接受的侵入性治疗较少，接受的临终关怀服务较多，死亡率较高。
年龄、血压、SAPS II和临终关怀服务可预测aSAH患者的抢救状态转变。识别高危患者有助于及时进行抢救状态讨论，确保治疗符合患者价值观，并在危急情况下改善家属决策。
