Withdrawal Of Care Research Articles

How Should Clinicians Discuss Deprescribing with Caregivers of Older Adults Living with Dementia? A Qualitative Study.

Preventive medications are potential targets for deprescribing in older adults with dementia as goals of care change from preventive to palliative. Yet, prescribers lack communication guidance to address deprescribing. Using bisphosphonates as a case example, we sought to characterize and compare communication preferences of prescribers and family/informal caregivers regarding deprescribing. We conducted 23 semi-structured interviews with prescribers (12) and caregivers (11) of older adults with Alzheimer's disease or related dementias (ADRD). Prescribers and caregivers were asked to provide their impressions of seven conversation starters for discussing deprescribing, focusing on a case example using bisphosphonates. These phrases focused on topics including life expectancy, treatment burden, adverse effects, and costs. We used a qualitative framework analysis to identify relevant themes as prescribers and caregivers discussed their general perceptions of the potential benefits and harms of bisphosphonates and experiences with deprescribing. Among prescribers, there were ten physicians and two nurse practitioners; most (nine) female and white. Among caregivers, eight were female, seven were white, and five were Latino/a. For both prescribers and caregivers, preferred conversation starters initiated a risk versus benefit discussion, emphasizing medication adverse effects and patient-specific factors, such as functional status and indication for treatment. While prescribers emphasized discussing common medication adverse effects, caregivers noted the importance of knowing a medication's potential impact on ADRD. The least preferred conversation starter for deprescribing among both groups focused on the extra effort and cost of continuing bisphosphonates. Discordance between caregivers and prescribers were identified in several phrases; notably, caregivers disliked statements that introduced discussions of prognosis and life expectancy. Deprescribing conversations may be best perceived by caregivers when introduced with a discussion of a medication's adverse effects and potential impact on cognition. In addition, deprescribing conversations should be tailored to patient-specific factors, including functional status, goals of care, and the role of their caregiver in medical decision-making. Avoiding discussions of medication cost, pill burden, and life expectancy may help reassure the caregiver that deprescribing is a form of medication optimization and not a withdrawal of care.

The efficacy and safety of thymosin α1 for sepsis (TESTS): multicentre, double blinded, randomised, placebo controlled, phase 3 trial

ObjectiveTo evaluate whether the immunomodulatory drug thymosin α1 reduces mortality in adults with sepsis.DesignMulticentre, double blinded, placebo controlled phase 3 trial.Setting22 centres in China, September 2016 to December 2020.Participants1106 adults...

Chronic Disease Management in Emergency Medicine

Chronic diseases now account for 86% of health care spending, and more than half of Americans live with a chronic illness, creating an epidemic. The rising incidence of chronic illness was not recognized or sufficiently addressed by the medical community or its leaders. As a result, a health-care crisis took place, with poor access and quality of service, as well as exorbitant expenses. With over half of Americans living with a chronic illness, chronic diseases now account for 86% of health care spending, causing an epidemic. The medical community and its leaders failed to acknowledge or adequately address the growing prevalence of chronic illness. As a result, a health-care crisis took place, with poor access and quality of service, as well as exorbitant expenses. They found that as a result, patient satisfaction rose, healthcare costs decreased, and patients' health outcomes improved. There was a significant overlap between the health care crisis and the rise of an epidemic of chronic diseases. Although the epidemic was not the cause of the crisis, it did play a significant part. The present challenge for the medical community and its leaders is to create a medical practice and a health care system that better meet the needs of those with chronic illnesses while simultaneously lowering the health care crisis. The importance of emergency preparedness plans for chronic conditions has been brought to light by recent crises, especially those that have occurred in wealthy nations. Many of the patients who survived had chronic conditions like diabetes, cancer, hypertension, and chronic respiratory diseases, which deteriorated due to stress from the disaster, care withdrawal, or both. For some of these patients, the exacerbations were lethal. In this paper, we review experiences from earlier disasters in developed nations and give guidelines for chronically sick patients' disaster preparedness. Based on lessons learned from recent disasters, numerous recommendations have been made that provide essential and useful protocols for managing chronic illness in emergency care.

Sub30: Feasibility study of a pre-hospital extracorporeal membrane oxygenation (ECMO) in patients with refractory out-of-hospital cardiac arrest in London, United Kingdom

AimSub30 study is an open-label, prospective, single-arm feasibility study with the primary objective of assessing the logistics, feasibility, and safety of ECPR delivery in a pre-hospital setting for refractory out-of-hospital cardiac arrest patients in London, United Kingdom. ResultsForty-three eligible patients were identified by London Ambulance Service over 27 trial recruitment days during a 13-month study period resulting in the despatch of the pre-hospital ECPR team to 18 patients. Five patients met full criteria and were cannulated for ECPR. All patients were male with a median age of 61 years and received ECPR full flows at a mean of 47 min (range 37–59 min) from initial collapse after a median travel time to scene of 14 min (range 3–20 min). No patient met the primary outcome measure of being established on pre-hospital ECPR within 30 min of the call to the emergency services. Out of 5 patients, 3 patients had care withdrawn and 2 survived to hospital discharge (both CPC score 3 and modified Rankin Score (mRS) score 4 and 5 respectively). MethodsOpen-label, single-arm, feasibility, prospective study. ConclusionsWhilst our study did not meet primary outcome of achieving full ECPR flow within 30-minute of collapse, it demonstrated safe, timely and effective delivery of ECPR with comparable survival rates by pre-hospital teams in a large metropolitan city and this has potential to improve outcomes in refractory out-of-hospital cardiac arrest patients.

Abstract 393: Rescue Intra‐arterial Therapy for Emergent Large Vessel Occlusion Secondary to Intracerebral Atherosclerotic Disease In the Philippines: A Single Center Study

Introduction Large vessel occlusions (LVO) secondary to intracranial atherosclerotic disease (ICAD) has an estimated prevalence of 10‐30% of all LVO cases, and the usual risk factors associated with it are hypertension, diabetes, ethnicity, and age. To date, the gold standard of treatment for strokes from LVO are intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). ICAD‐LVO results in increased morbidity and mortality, as well as early re‐occlusion after revascularization therapy. ICAD‐LVO results in re‐occlusion at 30‐50% compared to 5% rate in cardioembolic strokes. Rescue therapy (RT) for re‐stenosis or re‐occlusion includes intra‐arterial (IA) administration of antiplatelets, angioplasty, and emergency stenting. Despite advancements in endovascular therapy and medical management, the optimal approach for rescuing patients who fail initial reperfusion attempts remains a challenging and underexplored area. By documenting RT strategies, we can identify which are effective in such scenarios and ultimately its impact on clinical outcomes. Of note, this is the first study on RT in ICAD‐LVO in the Philippines. Methods A retrospective chart review of all emergent LVO who underwent cerebral angiogram for the purpose of endovascular thrombectomy from September 2018 to July 2024 was performed. Those included were patients who underwent rescue therapy for ICAD‐LVO. The following were collected, demographic data (age and sex), admitting MRS, NIHSS score upon admission, underlying co‐morbidities (hypertension, diabetes, history of previous stroke), use of anti‐thrombotics/anti‐coagulants as maintenance medications, ASPECTS or MR ASPECTS, history of IV thrombolysis administration, rescue therapy instituted (IA thrombolytics, stenting, or angioplasty), in‐hospital mortality, and discharge MRS. Results Among the 101 LVO patients reviewed, 10 of which were due to ICAD‐LVO and underwent rescue therapy. The mean age was 65 where 80% are male. The demographic data showed that all patients included were hypertensive and half are diabetic and dyslipidemic. 80% (n=8) of patients received IA tirofiban as RT with a mean dose of 960mcg, 1 underwent emergency stenting using a drug eluting coronary stent, and 1 received IA alteplase. No early neurological improvement was seen in those who received RT. For the immediate outcomes, 80% (n=8) of patients had an MRS of 3‐5 upon discharge. Regarding its safety, only 20% (n=2) had hemorrhagic transformation but were asymptomatic. Only 1 patient (10%) with a basilar ICAD‐LVO who received IA tirofiban died, but not as a direct result of the RT, but due to withdrawal of care. CONCLUSIONS ICAD‐LVO remains to be a challenging feat to overcome in revascularization therapy and results in worse outcomes. Rescue therapy with IA tirofiban seems to be safe but does not offer added benefit in terms of acute clinical outcomes. A study on long‐term outcomes of patients who received RT for ICAD‐LVO is recommended to better determine its safety and efficacy.

6980 A Case Report Of Severe Hypercalcemia In Acute Decompensated Liver Cirrhosis

Abstract Disclosure: M.M. Eid: None. R.M. Sargis: None. Introduction: Hypercalcemia in advanced liver disease in the absence of malignancy is a rare condition. Case: A 26 year old female with history of liver cirrhosis secondary to alcohol use disorder, presented with hematemesis and ascites. She was diagnosed with acute decompensated liver cell failure and transferred to our facility for liver transplantation. On Day 10 of her hospital course, she had an acute rise in serum calcium (Ca) to 10.8 mg/dl (N 8.7-10.5),albumin (Alb) 2.6 g/dl, corrected calcium (CCa) 11.9mg/dl. On day 13 Ca peaked to 13.5 mg/dl, CCa 14 mg/dl, ionized Ca 6.5mg/dl (N 4.2-5.4 mg/dl). Serum Ca was normal on day 9, Ca 8.7mg/dl, Alb 2.5 g/dl and CCa 9.9 mg/dl. She was not taking lithium, vitamin A or antacid. No personal or family history of bone disorder, fracture or kidney stone. On exam, blood pressure 85/45, heart rate 110 bpm, jaundiced with abdominal distension and respiratory distress. Labs: hemoglobin 8.1 g/dl, WBC 32.5K/Ul, platelet 136 K/Ul, serum creatinine 1.82 mg/dl, Na 133 mmol/l, K 3.5 mmol/l, Total/Direct bilirubin 29.9/18.1 mg/dl, alkaline phosphatase 166 U/L, AST/ALT 60/42U/l, Mag 2.3 mg/dl, Phos 5 mg/dl, INR 3, PTT 50 sec, parathyroid hormone (PTH) 12 pg/ml (N12-88), TSH 1.02 mciu/ml (N 0.34-4), 25 hydroxy vitamin D 17 ng/ml (N 20-80), parathyroid related peptide (PTHrP) 3.9 pmol/l (N<3.4), 1,25 di-hydroxy vitamin D 9.8 pg/ml (N 19.9-79.3), alpha fetoprotein 9.1 ng/ml (N <9). Normal anti smooth muscle and anti mitochondrial antibodies. Negative viral hepatitis serology. CT abdomen did not reveal hepatobiliary mass or tumor nor kidney stone. She was intubated and mechanically ventilated. Vasopressor support was initiated. One dose of calcitonin 4 units/kg and zoledronic acid 4 mg were given. Serum Ca decreased to 12 mg/dl, CCa 12.6 mg/dL then to 10.2 mg/dl, CCa 11mg/dl within hrs. Calcium normalized to 8.4mg/dl, CCa 9.2 mg/dl, ionized Ca 4.3 mg/dl within 24 hrs. Her condition deteriorated and withdrawal of care was decided. Conclusion: Our case demonstrates non PTH and non vitamin D mediated severe hypercalcemia in setting of acute decompensated cirrhosis and absence of malignancy. Previous literature has noted poor prognosis of hypercalcemia with acute decompensated cirrhosis. While hypercalcemia in cirrhosis may arise from paraneoplastic processes, in absence of malignancy it is speculated that acute hypercalcemia may arise from the inflammatory mediators inducing osteoclastic bone resorption as osteoclast activating factor, prostaglandin and immobilization. Some reports found an association between hypercalcemia and elevations in bilirubin and creatinine(1). Further research is needed to understand the pathophysiology and the management of hypercalcemia in acute decompensated cirrhosis.

National review of end-of-life care withdrawal guidelines for non-invasive advanced respiratory support using document analysis

ObjectivesThis study aims to understand the breadth of practice around end-of-life withdrawal of non-invasive advanced respiratory support (encompassing both continuous positive airway pressure and non-invasive ventilation) by analysing NHS-published guidelines...

Palliative Care and the Self-Fulfilling Prophecy in Stroke Patients: is There Anything to Fear? A Retrospective Study of Patients Who Died During Hospitalization in a Quaternary Care Hospital

Background and Purpose Primary palliative care (PC) aims to improve the quality of life for patients with acute ischemic stroke but is often misinterpreted as withdrawal of care. The self-fulfilling prophecy withdrawal bias is feared in this context of PC’s early implementation. This study evaluates stroke patients who died in the hospital to determine the impact of PC evaluation. Methods A retrospective descriptive analysis of patients who died from acute ischemic stroke was conducted. The study included patients aged ≥18 years admitted to the Stroke Unit of a quaternary hospital in Brazil from January 2017 to December 2018. The impact of PC assessment on outcomes was analyzed, with significance set at 5%. Results Among the patients who died during hospitalization as a result of an ischemic stroke (n = 77), 39 (%) were assessed by the palliative care team. There was no difference in the total length of stay or duration of antibiotic therapy. Logistic regression corrected for significant variables from the univariate analysis revealed that PC evaluation was associated with a 31-fold increase in opioid use ( P < 0.001), a nearly 14-fold increase in discharges to the ward, and a threefold reduction in ICU length of stay ( P = 0.011). Conclusion PC team involvement was associated with higher rates of discharge to the floors, inferring more time spent with family and increased opioid use, suggesting better symptom control, without reducing the overall length of stay or duration of antibiotic therapy. This underscores that PC does not equate to withdrawal of care.

Neuroprognostication, withdrawal of care and long-term outcomes after cardiopulmonary resuscitation.

Survivors of cardiac arrest often have increased long-term risks of mortality and disability that are primarily associated with hypoxic-ischemic brain injury (HIBI). This review aims to examine health-related long-term outcomes after cardiac arrest. A notable portion of cardiac arrest survivors face a decline in their quality of life, encountering persistent physical, cognitive, and mental health challenges emerging years after the initial event. Within the first-year postarrest, survivors are at elevated risk for stroke, epilepsy, and psychiatric conditions, along with a heightened susceptibility to developing dementia. Addressing these challenges necessitates establishing comprehensive, multidisciplinary care systems tailored to the needs of these individuals. HIBI remains the leading cause of disability among cardiac arrest survivors. No single strategy is likely to improve long term outcomes after cardiac arrest. A multimodal neuroprognostication approach (clinical examination, imaging, neurophysiology, and biomarkers) is recommended by guidelines, but fails to predict long-term outcomes. Cardiac arrest survivors often experience long-term disabilities that negatively impact their quality of life. The likelihood of such outcomes implements a multidisciplinary care an integral part of long-term recovery.

Healthcare Worker Attitudes to Living Donation Prior to Planned Withdrawal of Care.

This study assesses the attitudes of healthcare practitioners toward Living Donation Prior to Planned Withdrawal of Care (LD-PPW): the recovery of a living donor organ before withdrawal of life-sustaining measures in a patient who does not meet criteria for brain death, but for whom medical care toward meaningful recovery is deemed futile. An electronic survey was administered to 1735 members of the American Society of Transplant Surgeons mailing list with 187 responses (10.8%). Data from this study revealed that 70% of responding practitioners agreed with LD-PPW due to principles of beneficence and autonomy. Also, 65% of participants felt confident in their ability to declare the futility of care and 70% felt that LD-PPW should be added as an option when registering to become an organ donor. Currently, nearly half of all donation after circulatory determination of death do not proceed to donation. LD-PPW has been proposed as an alternative procedure targeted at increasing the quality and quantity of transplantable organs while respecting the donor's right to donate, though its implementation has been hindered by concerns over public and provider perception. This study revealed support for LD-PPW among healthcare practitioners as an alternative procedure to increase the quality and quantity of transplantable organs while respecting the donor's right to donate.

Trauma patients with metastatic cancer undergoing emergent surgery: A matched cohort analysis

BackgroundThere is a paucity of literature guiding trauma surgeons in the care of patients with active metastatic cancer (MC). Even less is known regarding outcomes for MC patients requiring emergent surgery after trauma. We hypothesized that trauma patients with active Metastatic Cancer (MC) have an increased mortality rate and undergo increased rates of withdrawal of care (WoC) within 72-hours following emergent operations, compared to similarly matched patients without MC. MethodsPatients with active MC at the time of traumatic injury were matched 1:2 against patients without active MC based on demographics, comorbidities, vital signs on admission, and injury profile. ResultsFrom 43,826 patients, 0.2 % had MC. After matching 39 MC patients to 78 without MC, there was no difference in demographics, comorbidities, injury severity score, mechanism of injury, vitals on admission (blood pressure, heart rate, respiration rate) and need for blood transfusion (all p > 0.05). Compared to patients without MC, patients with MC had higher rates and associated risk of death during index hospitalization (38.5 % vs. 15.2 %, p = 0.005; OR 3.49, CI 1.43–8.51, p = 0.006), as well as a higher rate and associated risk of WoC within 72-hours (12.8 % vs. 1.3 %, p = 0.007; OR 11.47, CI 1.29–101.93, p = 0.029). ConclusionTrauma patients with MC requiring emergent thoracic or abdominal surgery have a high risk of death and an over ten-fold higher associated risk for WoC within the first three days. In some cases, palliative care consultation should be considered, and counseling should be offered to this high-risk trauma population to enable individualized and patient-centric decisions. Key messageThis research highlights the importance of a multidisciplinary team consisting of trauma surgeons, oncologist, and palliative care physicians in caring for the high-risk trauma patients with disseminated cancer requiring urgent surgery.

Treatment time limit for successful weaning from veno-arterial extracorporeal membrane oxygenation in cardiogenic shock.

Knowing the upper time limit for successful weaning from temporary mechanical circulatory support in cardiogenic shock will help with decision-making regarding advanced heart failure (HF) therapy or considering withdrawal of care. The aim of this study was to investigate the association between the support duration and successful weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock. A retrospective single-centre cohort study was conducted between January 2013 and June 2023. It included 100 consecutive patients with cardiogenic shock who were treated with VA-ECMO. Patients with out-of-hospital cardiac arrest were excluded. The primary outcome was successful weaning from VA-ECMO (i.e., VA-ECMO decannulation and survival to discharge). The association between the length of support duration and the weaning success rate was analysed. Patients were divided into three groups according to ECMO support duration: Group A (≤7days), Group B (8-14days), and Group C (≥15days). Multivariable logistic regression analysis was used to evaluate the impact of the length of support duration on successful weaning of VA-ECMO. The median age was 67years, and 73% of study participants were male. The underlying aetiologies of cardiogenic shock were as follows: acute myocardial infarction, 50; fulminant myocarditis, 19; cardiomyopathy, 15; valvular heart disease, 8; and other, 8. Seventy-five patients (75%) were attempted to wean VA-ECMO, and 67 moved on to decannulation. In total, 43 (43%) patients were successfully weaned from VA-ECMO. The median length of ECMO support duration was 8 [3-15] days. Compared with those who underwent successful ECMO decannulation, those who did not had a significantly longer support duration of VA-ECMO (5 [3-9] days vs. 12 [3-22] days, P=0.004). The weaning success rate was significantly higher in patients with short support duration; 58% (29/50), 40% (10/25), 16% (4/25) in Groups A, B, and C, respectively (P=0.002). Overall, none of the patients supported for over 24days (0/11) were successfully weaned from VA-ECMO. On multivariable logistic regression analysis, the length of support duration was independently associated with successful weaning after adjusting for age, sex, underlying aetiology, and left ventricular ejection fraction (odds ratio, 0.813 [per 3days]; 95% confidence interval, 0.679-0.914; P=0.025). Long support duration of VA-ECMO was significantly associated with a low rate of successful weaning in patients with cardiogenic shock. Patients who require VA-ECMO for over 1week should start considering advanced HF therapy or withdrawal of care.

Clinical Factors Associated With Mode of Death Following Cardiac Arrest

Background Death after resuscitation from cardiac arrest is common. Although associated factors have been identified, knowledge about their relationship with specific modes of death is limited. Objective To identify clinical factors associated with specific modes of death following cardiac arrest. Methods This study involved a retrospective medical record review of patients admitted to a single health care center from January 2015 to March 2020 after resuscitation from cardiac arrest who died during their index hospitalization. Mode of death was categorized as either brain death, withdrawal of life-sustaining therapies due to neurologic causes, death due to medical causes, or withdrawal of life-sustaining therapies due to patient preference. Clinical characteristics across modes of death were compared. Results The analysis included 731 patients. Death due to medical causes was the most common mode of death. Compared with the other groups of patients, those with brain death were younger, had fewer comorbidities, were more likely to have experienced unwitnessed and longer cardiac arrest, and had more severe acidosis and hyperglycemia on presentation. Patients who died owing to medical causes or withdrawal of life-sustaining therapies due to patient preference were older and had more comorbidities, fewer unfavorable cardiac arrest characteristics, and fewer days between cardiac arrest and death. Conclusions Significant associations were found between several clinical characteristics and specific mode of death following cardiac arrest. Decision-making regarding withdrawal of care after resuscitation from cardiac arrest should be based on a multimodal approach that takes account of a variety of personal and clinical factors.

Association of timing and agent for venous thromboembolism prophylaxis in patients with severe traumatic brain injury on venous thromboembolism events, mortality, neurosurgical intervention, and discharge disposition.

Trauma patients are at increased risk for venous thromboembolism events (VTEs). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI). This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (Abbreviated Injury Scale head score of 3, 4, or 5). Data were collected at 35 Level 1 and 2 trauma centers from January 1, 2017, to June 1, 2022. Patients were placed into analysis cohorts: no VTEP, low-molecular-weight heparin (LMWH) ≤48 hours, LMWH >48 hours, heparin ≤48 hours, and heparin >48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTEs, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage. Of 12,879 patients, 32% had no VTEP, 36% had LMWH, and 32% had heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH ≤48 hours (4.1%). Venous thromboembolism event rates were lower with use of LMWH (1.6% vs. 4.5%; odds ratio, 2.98; 95% confidence interval, 1.40-6.34; p = 0.005) without increasing mortality or neurosurgical interventions. Venous thromboembolism event rates were lower with early prophylaxis (2.0% vs. 3.5%; odds ratio, 1.76; 95% confidence interval, 1.15-2.71; p = 0.01) without increasing mortality ( p = 1.0). Early VTEP was associated with more nonfatal intracranial operations ( p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition ( p = 0.7, p = 0.1, p = 0.5). In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP ≤48 hours decreased VTE incidence and increased nonfatal neurosurgical interventions without affecting mortality. Low-molecular-weight heparin is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits. Therapeutic/Care Management; Level III.

End of life decision making when home mechanical ventilation is used to sustain breathing in Motor Neurone Disease: patient and family perspectives

BackgroundMotor Neurone Disease (MND) leads to muscle weakening, affecting movement, speech, and breathing. Home mechanical ventilation, particularly non-invasive ventilation (NIV), is used to alleviate symptoms and support breathing in people living with MND. While home mechanical ventilation can alleviate symptoms and improve survival, it does not slow the progression of MND. This study addresses gaps in understanding end-of-life decision-making in those dependent on home mechanical ventilation, considering the perspectives of patients, family members, and bereaved families.MethodsA UK-wide qualitative study using flexible interviews to explore the experiences of people living with MND (n = 16), their family members (n = 10), and bereaved family members (n = 36) about the use of home mechanical ventilation at the end of life.ResultsSome participants expressed a reluctance to discuss end-of-life decisions, often framed as a desire to “live for the day” due to the considerable uncertainty faced by those with MND. Participants who avoided end-of-life discussions often engaged in ‘selective decision-making’ related to personal planning, involving practical and emotional preparations. Many faced challenges in hypothesising about future decisions given the unpredictability of the disease, opting to make ‘timely decisions’ as and when needed. For those who became dependent on ventilation and did not want to discuss end of life, decisions were often ‘defaulted’ to others, especially once capacity was lost. ‘Proactive decisions’, including advance care planning and withdrawal of treatment, were found to empower some patients, providing a sense of control over the timing of their death. A significant proportion lacked a clear understanding of the dying process and available options.ConclusionsThe study highlights the complexity and evolution of decision-making, often influenced by the dynamic and uncertain nature of MND. The study emphasises the need for a nuanced understanding of decision-making in the context of MND.

Short-term functional outcomes of patients with acute intracerebral hemorrhage in the native and expatriate population.

Functional outcomes in patients with intracerebral hemorrhage (ICH) have not been well characterized in the Middle East and North Africa Region. We report the 30 and 90-day clinical outcomes in the native and expatriate of Qatar with ICH. We evaluated the Glasgow Coma Scale (GCS), NIHSS, and imaging in the Qatar Stroke Registry (2013-22). The outcome measures were a modified Rankin Scale (mRS) at 90 days and mortality at 30 and 90 days. Unfavorable outcome was defined as mRS of 4-6. We performed non-parametric ROC analyses to measure the concordance index (C-index) to assess the goodness-of-fit of ICH score for predicting 30 day and 90-day mortality and functional outcome. 1,660 patients (median age of 49 (41.5-58) years; male 83.1%, expatriates 77.5%) with ICH, including supratentorial deep in 65.2%, cortical in 16.2%, infratentorial 16% and primary intraventricular in 2.5% were studied. The median baseline ICH volume was 7.5 (3.2-15.8) ml. An unfavorable outcome was seen in 673 (40.5%) patients at 90 days. The unfavorable 90-day outcome (mRS 4-6) was 49.2% in the native population vs. 44.4% in Africans, 39.0% in South Asian, 35.3% in Far Eastern, and 7.7% in Caucasians, p < 0.001. Mortality at 30 days and 90 days was 10.4 and 15.1%. Increasing age [OR (95% CI), 1.02 (1.00-1.03)], lower GCS [0.77 (0.73-0.80)], prior use of antiplatelet medications [1.82 (1.19-2.08)], higher ICH volume [1.03 (1.02-1.04)], and presence of any intraventricular hemorrhage [1.57(1.19-2.08)], were associated with unfavorable outcome. In this relatively younger ICH cohort more than 75% were expatriates. The ICH volume, 90-day unfavorable outcome and mortality was lower in the expatriates compared to the local Arab population, likely related to the younger age and smaller size of the hemorrhages. Prognostic scoring systems may have to be modified in this population to avoid early withdrawal of care.

Waiting with Beckett in the Anthropocene.

This article asks what we might make of Samuel Beckett’s persistent aesthetic and ethical commitment to waiting during a moment shot through with calls to action in the face of extinction events and climate catastrophe. Concentrating on Beckett’s ‘grey time’ and interest in Freud’s death drive, I argue that Beckett’s work uses the temporal suspension of the ‘meanwhile’ to attend to how bodies and selves endure through time when there has been a withdrawal of care for the version of the human that has imagined itself able to produce and mark the end of multiple human and more-than-human others. Beckett’s scenes of endless ending, as forms of what Leo Bersani might call ‘willed lessness’, carefully return us to the ongoing relationship within and between human and more-than-human worlds, sustained according to different configurations of intensity. In the place of action, what persists in the ‘meanwhile’ is a drive that ‘de-dramatizes’ the human as a ‘subject of knowledge’, so that things might die in their own time and after their own fashion.

Acute decompensation of cirrhosis versus acute-on-chronic liver failure: What are the clinical implications?

It is essential to identify the subgroup of patients who experience poorer outcomes in order to adapt clinical management effectively. In the context of liver disease, the earlier the identification occurs, the greater the range of therapeutic options that can be offered to patients. In the past, patients with acute decompensation (AD) of chronic liver disease were treated as a homogeneous group, with emphasis on identifying those at the highest risk of death. In the last 15years, a differentiation has emerged between acute-on-chronic liver failure syndrome (ACLF) and AD, primarily due to indications that the latter is linked to a less favorable short-term prognosis. Nevertheless, the definition of ACLF varies among the different knowledge societies, making it challenging to assess its true impact compared with AD. Therefore, the purpose of this review is to provide a detailed analysis emphasizing the critical importance of identifying ACLF in the field of advanced liver disease. We will discuss the differences between Eastern and Western approaches, particularly in relation to the occurrence of liver failure and disease onset. Common characteristics, such as the dynamic nature of the disease course, will be highlighted. Finally, we will focus on two key clinical implications arising from these considerations: the prevention of ACLF before its onset and the clinical management strategies once it develops, including liver transplantation and withdrawal of care.

Abstract 155: Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial

Background/hypothesis: The SELECT2 trial randomly assigned patients with LVO and large ischemic cores to either endovascular thrombectomy (EVT) or medical management (MM). This population is at high risk for cerebral edema and other complications, often leading to critical decisions about decompressive hemicraniectomy (DHC) or early withdrawal of care (WOC). We hypothesized that patients initially treated with EVT were more likely to get life-sustaining care regardless of recanalization success, presumably because initial treatment with EVT led toward an expectation of aggressive care, while those treated with MM expected futility. Methods: We analyzed the full SELECT2 study population using the as-treated principle, comparing the use of DHC and early (within 7 days from randomization) transition to comfort measures/WOC. We also compared these decisions based on recanalization success in those receiving EVT. We further tested baseline characteristics for association with these outcomes. Results: Patients treated with EVT were as likely to undergo DHC (aRR:1.19 [0.75-1.88], p=0.46) or WOC (aRR:0.94 [0.66-1.34], p=0.72) as those given MM (Table). Time to DHC was also similar (EVT 47[19-74] vs. MM 36[27-61] hours, p=0.95). Patients with successful (mTICI≥2b) recanalization were numerically less likely to undergo DHC than those with unsuccessful (TICI 0-2a) recanalization (aRR:0.66 [0.33-1.3], p=0.23), while WOC was similar (Table). Larger estimated core volumes were associated with both DHC and WOC, with DHC used more in younger and WOC more in older patients. Conclusions: In the SELECT2 trial of patients with large infarct cores, DHC was performed in ~1 in 6 and WOC in ~1 in 5, without an observed difference based on treatment with EVT or MM. The similar distribution of decisions to proceed with DHC or to change goals of care to acute palliative measures provides reassurance that the overall trial outcomes were not biased by open-label treatment allocation.

Abstract 46: Minimally Invasive Surgery is Associated With Lower Mortality After Spontaneous Intracerebral Hemorrhage in the Get With the Guidelines Registry

Introduction: The efficacy of emergent minimally invasive surgery (MIS) in improving outcomes after non-traumatic intracerebral hemorrhage (ICH) is unclear, with two randomized clinical trials (MISTIE III and ENRICH) showing conflicting results. We therefore sought to evaluate the association of MIS for ICH with outcomes in a real-world, nationally representative cohort. Methods: We performed a retrospective cohort study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients who underwent open craniotomy/craniectomy and those transferred to another hospital were excluded. The study exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality. In the primary analysis, we matched patients who underwent MIS with medically managed patients in a 1:1 manner on age, sex, race, NIH Stroke Scale, prior antithrombotic therapy, and external ventricular drain use. Logistic regression was used while adjusting for withdrawal of care. In secondary analyses, stereotactic and endoscopic surgical approaches were analyzed separately. Results: Among 555,964 patients with ICH, MIS was performed in 703 patients (330 had stereotactic surgery; 391 had endoscopic surgery). The matched cohort included 485 patients in each group. Median time to surgery was 1 day (IQR, 1-2). In-hospital deaths occurred in 63 (13%) with MIS and 96 (20%) without surgery. Medically managed patients had more vascular comorbidities such as hypertension, diabetes, and prior stroke than those who underwent MIS. In regression analyses adjusted for withdrawal of care, MIS was associated with lower in-hospital mortality at discharge (aOR, 0.4; CI, 0.3-0.6). In secondary analyses, stereotactic surgery (aOR, 0.3; CI, 0.2-0.6) and endoscopic surgery (aOR, 0.6; CI, 0.3-0.9) were also independently associated with lower mortality. Conclusions: In a large heterogeneous US cohort of ICH patients, emergent MIS was associated with lower in-hospital mortality. Longer-term follow up data with ascertainment of functional outcomes may shed more light on the benefit of surgery after ICH.