Minority Patients are Less Likely to Undergo Withdrawal of Care After Spontaneous Intracerebral Hemorrhage
Prior studies of patients in the intensive care unit have suggested racial/ethnic variation in end-of-life decision making. We sought to evaluate whether race/ethnicity modifies the implementation of comfort measures only status (CMOs) in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH).
We analyzed data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a prospective cohort study specifically designed to enroll equal numbers of white, black, and Hispanic subjects. ICH patients aged ≥ 18 years were enrolled in ERICH at 42 hospitals in the USA from 2010 to 2015. Univariate and multivariate logistic regression analyses were implemented to evaluate the association between race/ethnicity and CMOs after adjustment for potential confounders.
A total of 2705 ICH cases (912 black, 893 Hispanic, 900 white) were included in this study (mean age 62 [SD 14], female sex 1119 [41%]). CMOs patients comprised 276 (10%) of the entire cohort; of these, 64 (7%) were black, 79 (9%) Hispanic, and 133 (15%) white (univariate p < 0.001). In multivariate analysis, compared to whites, blacks were half as likely to be made CMOs (OR 0.50, 95% CI 0.34–0.75; p = 0.001), and no statistically significant difference was observed for Hispanics. All three racial/ethnic groups had similar mortality rates at discharge (whites 12%, blacks 9%, and Hispanics 10%; p = 0.108). Other factors independently associated with CMOs included age (p < 0.001), premorbid modified Rankin Scale (p < 0.001), dementia (p = 0.008), admission Glasgow Coma Scale (p = 0.009), hematoma volume (p < 0.001), intraventricular hematoma volume (p < 0.001), lobar (p = 0.032) and brainstem (p < 0.001) location and endotracheal intubation (p < 0.001).
In ICH, black patients are less likely than white patients to have CMOs. However, in-hospital mortality is similar across all racial/ethnic groups. Further investigation is warranted to better understand the causes and implications of racial disparities in CMO decisions.
KeywordsEnd-of-life care Race and ethnicity Intracerebral hemorrhage
CHO, GJF, DMM, KNS, DW were involved in conception and design of the study. CHO, GJF, DMM, ACL, LCM, KNS, DW, CDL contributed to acquisition and analysis of data. CHO, GJF, SDJ, DMM, DYH, KNS, MLJ, FDT, KJB, DLT, DW drafted a significant portion of the manuscript or figures.
Source of Support
This study was supported by a grant from the National Institute of Neurological Disorders and Stroke (NINDS: U-01-NS069763). This report does not represent the official view of NINDS, the National Institutes of Health (NIH), or any part of the US Federal Government. No official support or endorsement of this article by NINDS or NIH is intended or should be inferred.
Dr. Falcone is supported by a Yale Pepper Scholar Award (P30AG021342) and the Neurocritical Care Society Research Fellowship. The other authors have no disclosures.
This study was supported by a research grant from the National Institute of Neurological Disorders (NINDS: U01-NS069763).
Compliance with Ethical Standards
Conflict of interest
All authors report no competing interests relevant to the manuscript.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- 12.Woo D, Rosand J, Kidwell C, et al. The ethnic/racial variations of intracerebral hemorrhage (ERICH) study protocol. Stroke. 2013;44:e120–5.Google Scholar
- 28.Faigle R, Marsh EB, Llinas RH, Urrutia VC, Gottesman RF. Race-specific predictors of mortality in intracerebral hemorrhage: differential impacts of intraventricular hemorrhage and age among blacks and whites. J Am Heart Assoc 2016; 5:1–8.Google Scholar