Abstract WP443: The Impact of Delirium and Impaired Consciousness on Withdrawal of Life-Sustaining Treatment After Spontaneous Intracerebral Hemorrhage

Abstract

Introduction: Established predictors for outcome after intracerebral hemorrhage (ICH) may be subject to self-fulfilling prophecy, as studies examining their effects on mortality have generally not considered changes in code status leading to withdrawal of life-sustaining treatment (WLST). We aimed to identify factors specifically associated with WLST, and hypothesized that impaired consciousness and delirium would be especially implicated. Methods: We analyzed data from consecutive patients admitted with ICH from February-June 2018. ICH score and other clinical predictors were prospectively adjudicated, and most patients had delirium assessments performed by an expert clinician; for those who did not, we established the presence of probable delirium via chart review. Using logistic regression models that adjusted for ICH severity, we determined the association of impaired consciousness on admission (Glasgow Coma Scale [GCS] <13) with early WLST (defined as <24 hours from admission), and the presence of delirium on subsequent assessments with WLST after 24 hours. Results: Of 106 patients in our cohort (mean age 68.7 [SD 17.8], median ICH score 1.5 [IQR 1-2]), WLST occurred in 29% (22/40 with admission GCS <13, 9/66 with GCS 13-15). After adjusting for ICH severity, admission GCS <13 was more strongly associated with early WLST (OR 26.8, 95% CI 2.8-255.8) than other components of the ICH score (OR 9.9, 95% CI 1.5-67.0 for age >80; OR 8.4, 95% CI 1.7-40.7 for size >30cc; intraventricular hemorrhage and infratentorial location were not significant). Of 92 patients who survived >24 hours without early WLST, 52% had delirium. We found that delirious patients were significantly more likely than patients without delirium to have subsequent WLST (33% vs. 2%, p<0.001; OR 18.8, 95% CI 2.1-165.5 after adjusting for ICH severity). Finally, we found that a composite predictor—initial GCS <13 or subsequent delirium—was strongly associated with WLST at any time during hospitalization (OR 19.0, 95% CI 2.3-158.0 after adjusting for ICH severity). Conclusion: Impaired consciousness and delirium likely play a significant role in WLST after ICH. However, whether this phenomenon is due to effects on clinician or surrogate decision-making remains unclear.