Date of Award
Medical Doctor (MD)
David M. Greer
Withdrawal of life-sustaining therapy (WLST) due to predicted poor neurologic outcome is a major cause of death in post-cardiac arrest patients. Neuroprognostication is challenging as outcomes studies are limited by self-fulfilling prophecy bias. Given the impact of neurologic prognosis on mortality, the use of reliable, evidence-based prediction methods is critical. The purpose of this two-part study is to investigate physicians’ practical approach to neuroprognostication and WLST after cardiac arrest.
Part I is a single-center, retrospective analysis of a cohort of 144 post-cardiac arrest patients. Clinical findings, test results, and timing and rationale for WLST were abstracted from the medical record. Part II is a 28-question survey of physicians in the United States and abroad who manage post-cardiac arrest patients. A total of 895 respondents provided data on technique and the perceived value of each prognostic test. All data was analyzed using descriptive statistical methods.
WLST due to poor neurologic prognosis accounted for 61% of deaths in the single-center cohort. Results of both studies suggest that physicians used multiple modalities to assess prognosis, but often in a way inconsistent with evidence-based recommendations. Rationale for WLST referred generally to poor neurologic prognosis (e.g., “no chance of meaningful recovery”) rather than specific indicators. WLST in the absence of rigorous prognostic indicators undermines accurate neurologic prognostication in post-cardiac arrest patients and perpetuates a self-fulfilling prophecy of poor outcome.
Barden, Mary Michele, "Neuroprognostication And Withdrawal Of Life-Sustaining Therapy In Post-Cardiac Arrest Patients" (2017). Yale Medicine Thesis Digital Library. 2110.