Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies
Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies
复制标题
DOI：
10.1212/wnl.56.6.766
复制
发表时间：
2001-03-27
期刊：
影响因子：
9.9
通讯作者：
Longstreth, WT
中科院分区：
文献类型：
--
作者：
Becker, KJ;Baxter, AB;Longstreth, WT
背景：严重脑损伤患者撤销支持总是导致死亡。关于脑出血（ICH）患者护理无效的先入为主的观念可能会促使患者退出支持，而在患者群体中退出支持的建模结果可能会导致自我实现的预言。方法：研究对象为连续的幕上脑出血患者。评估出血的影像学特征、临床变量和神经系统预后。通过书面调查和病例介绍，研究了神经内科和神经外科成员对护理无效的态度。结果：幕上脑出血87例；总死亡率为34.5%（30/87）。格拉斯哥昏迷评分小于或等于8、脑出血体积小于或等于60 cm的患者死亡率为66.7%（18/27）。76.7%（23/30）的死亡患者撤销了医疗支持。在预测结果的模型中纳入一个变量来解释支持撤回，否定了所有其他变量的预测价值。接受手术减压的患者不太可能撤销支持，老年患者（p < 0.01）和左半球出血患者（p = 0.04）手术的可能性较小。调查结果表明，从业人员倾向于过于悲观的预测结果，基于数据的基础上，在提出的时间。结论：决定脑出血后预后的最重要的预后变量是所提供的医疗支持水平。在患者感觉可能会有“糟糕的结果”时，撤回支持会使预测模型产生偏差，并导致自我实现的预言。我们的数据表明，传统上“预后差”类别的个体患者在积极治疗时可以有合理的神经系统预后。
Background: Withdrawal of support in patients with severe brain injury invariably leads to death. Preconceived notions about futility of care in patients with intracerebral hemorrhage (ICH) may prompt withdrawal of support, and modeling outcome in patient populations in whom withdrawal of support occurs may lead to self-fulfilling prophecies. Methods: Subjects included consecutive patients with supratentorial ICH. Radiographic characteristics of the hemorrhage, clinical variables, and neurologic outcome were assessed. Attitudes about futility of care were examined among members of the departments of neurology and neurologic surgery through a written survey and case presentations. Results: There were 87 patients with supratentorial ICH; overall mortality was 34.5% (30/87). Mortality was 66.7% (18/27) in patients with Glasgow Coma Score less than or equal to8 and ICH volume >60 cm(3). Medical support was withdrawn in 76.7% (23/30) of patients who died. Inclusion of a variable to account for the withdrawal of support in a model predicting outcome negated the predictive value of all other variables. Patients undergoing surgical decompression were unlikely to have support withdrawn, and surgery was less likely to be performed in older patients (p < 0.01) and patients with left hemispheric hemorrhage (p = 0.04). Survey results suggested that practitioners tend to be overly pessimistic in prognosticating outcome based upon data available at the time of presentation. Conclusions: The most important prognostic variable in determining outcome after ICH is the level of medical support provided. Withdrawal of support in patients felt likely to have a "poor outcome" biases predictive models and leads to self-fulfilling prophecies. Our data show that individual patients in traditionally "poor outcome" categories can have a reasonable neurologic outcome when treated aggressively.