Some stroke patients whose life support is withdrawn may have achieved a less-than-ideal

February 7, 2013, American Heart Association

More than a third of patients who suffer a major bleeding in the brain and have their life support withdrawn might have eventually regained an acceptable level of functioning if life support had been sustained, suggests a new study presented at the American Stroke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 , causing .

The new study, initially encompassing 590 at a Seattle hospital, was designed to see whether "self-fulfilling prognostic ," 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Researchers identified 78 patients whose life support was withdrawn and compared their outcomes with 78 similar patients who were not removed from life support.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At , only 4 percent of matched patients whose life support was withdrawn had an acceptable outcome, compared with 38 percent of the matches who did not have life support withdrawn—suggesting 34 percent of the group whose support was withdrawn might also have had an acceptable outcome if support had been sustained.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 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 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."

Explore further: Native Hawaiians have bleeding strokes at earlier age, independent of meth use

Related Stories

Native Hawaiians have bleeding strokes at earlier age, independent of meth use

February 6, 2013
Native Hawaiians and Pacific Islanders have more bleeding strokes at an earlier age than other people independent of methamphetamine abuse, according to research presented at the American Stroke Association's International ...

Study finds no link between intracerebral hemorrhage and statin use among patients with prior stroke

September 12, 2011
Among patients who have had an ischemic stroke, use of cholesterol-lowering statin medications is not associated with subsequent intracerebral hemorrhage (bleeding in the brain), according to a report published Online First ...

Cholesterol-lowering statin drugs can reduce the risk of stroke, but sometimes should be avoided

August 19, 2011
For many patients, cholesterol-lowering statin drugs can reduce the risk of strokes as well as heart attacks. But in a review article, Loyola University Health System neurologists caution that statins may not be appropriate ...

Withdrawing life support for traumatic brain injuries needs cautious approach

August 29, 2011
Death following severe traumatic brain injury is associated with a highly variable incidence of withdrawal of life support at the end of life, finds a new study in CMAJ. Rates of withdrawal of life support vary between hospitals, ...

Recommended for you

A nanoparticle inhalant for treating heart disease

January 18, 2018
A team of researchers from Italy and Germany has developed a nanoparticle inhalant for treating people suffering from heart disease. In their paper published in the journal Science Translational Medicine, the group describes ...

Starting periods before age of 12 linked to heightened risk of heart disease and stroke

January 15, 2018
Starting periods early—before the age of 12—is linked to a heightened risk of heart disease and stroke in later life, suggests an analysis of data from the UK Biobank study, published online in the journal Heart.

'Decorated' stem cells could offer targeted heart repair

January 10, 2018
Although cardiac stem cell therapy is a promising treatment for heart attack patients, directing the cells to the site of an injury - and getting them to stay there - remains challenging. In a new pilot study using an animal ...

Two simple tests could help to pinpoint cause of stroke

January 10, 2018
Detecting the cause of the deadliest form of stroke could be improved by a simple blood test added alongside a routine brain scan, research suggests.

Exercise is good for the heart, high blood pressure is bad—researchers find out why

January 10, 2018
When the heart is put under stress during exercise, it is considered healthy. Yet stress due to high blood pressure is bad for the heart. Why? And is this always the case? Researchers of the German Centre for Cardiovascular ...

Heart-muscle patches made with human cells improve heart attack recovery

January 10, 2018
Large, human cardiac-muscle patches created in the lab have been tested, for the first time, on large animals in a heart attack model. This clinically relevant approach showed that the patches significantly improved recovery ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.