Skip to main content

Advertisement

SpringerLink
Log in

Minority Patients are Less Likely to Undergo Withdrawal of Care After Spontaneous Intracerebral Hemorrhage

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

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).

Methods

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.

Results

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).

Conclusions

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56:766–72.

    Article  CAS  PubMed  Google Scholar 

  2. Hwang DY, Dell CA, Sparks MJ, et al. Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes. Neurology. 2016;86:126–33.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Cai X, Robinson J, Muehlschlegel S, et al. Patient preferences and surrogate decision making in neuroscience intensive care units. Neurocrit Care. 2015;23:131–41.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Holloway RG, Benesch CG, Burgin WS, Zentner JB. Prognosis and decision making in severe stroke. JAMA. 2005;294:725–33.

    Article  CAS  PubMed  Google Scholar 

  5. Cooper Z, Rivara FP, Wang J, MacKenzie EJ, Jurkovich GJ. Racial disparities in intensity of care at the end-of-life: are trauma patients the same as the rest? J Health Care Poor Underserved. 2012;23:857–74.

    Article  PubMed  Google Scholar 

  6. Shepardson LB, Gordon HS, Ibrahim SA, Harper DL, Rosenthal GE. Racial variation in the use of do-not-resuscitate orders. J Gen Intern Med. 1999;14:15–20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Bardach N, Zhao S, Pantilat S, Johnston SC. Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities. Am J Med. 2005;118:400–8.

    Article  PubMed  Google Scholar 

  8. Qureshi AI, Adil MM, Suri MF. Rate of use and determinants of withdrawal of care among patients with subarachnoid hemorrhage in the United States. World Neurosurg. 2014;82:e579–84.

    Article  PubMed  Google Scholar 

  9. Diringer MN, Edwards DF, Aiyagari V, Hollingsworth H. Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit. Crit Care Med. 2001;29:1792–7.

    Article  CAS  PubMed  Google Scholar 

  10. Rubin MA, Dhar R, Diringer MN. Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients. J Crit Care. 2014;29:49–53.

    Article  PubMed  Google Scholar 

  11. Choi HA, Fernandez A, Jeon SB, et al. Ethnic disparities in end-of-life care after subarachnoid hemorrhage. Neurocrit Care. 2015;22:423–8.

    Article  PubMed  Google Scholar 

  12. Woo D, Rosand J, Kidwell C, et al. The ethnic/racial variations of intracerebral hemorrhage (ERICH) study protocol. Stroke. 2013;44:e120–5.

    PubMed  Google Scholar 

  13. Sheth KN, Martini SR, Moomaw CJ, et al. Prophylactic antiepileptic drug use and outcome in the ethnic/racial variations of intracerebral hemorrhage study. Stroke. 2015;46:3532–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Siddiqui FM, Langefeld CD, Moomaw CJ, et al. Use of statins and outcomes in intracerebral hemorrhage patients. Stroke. 2017;48:2098–104.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.

    Article  PubMed  Google Scholar 

  16. Rost NS, Smith EE, Chang Y, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke. 2008;39:2304–9.

    Article  PubMed  Google Scholar 

  17. Zurasky JA, Aiyagari V, Zazulia AR, Shackelford A, Diringer MN. Early mortality following spontaneous intracerebral hemorrhage. Neurology. 2005;64:725–7.

    Article  CAS  PubMed  Google Scholar 

  18. Zahuranec DB, Brown DL, Lisabeth LD, et al. Ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage. Crit Care Med. 2009;37:2807–11.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Hanchate A, Kronman AC, Young-Xu Y, Ash AS, Emanuel E. Racial and ethnic differences in end-of-life costs: why do minorities cost more than whites? Arch Intern Med. 2009;169:493–501.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Crawley L, Payne R, Bolden J, Payne T, Washington P, Williams S. Palliative and end-of-life care in the African American community. JAMA. 2000;284:2518–21.

    Article  CAS  PubMed  Google Scholar 

  21. Rhodes RL, Elwood B, Lee SC, Tiro JA, Halm EA, Skinner CS. The desires of their hearts: the multidisciplinary perspectives of African Americans on end-of-life care in the African American community. Am J Hosp Palliat Care. 2017;34:510–7.

    Article  PubMed  Google Scholar 

  22. Johnson KS, Kuchibhatla M, Tulsky JA. What explains racial differences in the use of advance directives and attitudes toward hospice care? J Am Geriatr Soc. 2008;56:1953–8.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Rhodes RL, Batchelor K, Lee SC, Halm EA. Barriers to end-of-life care for African Americans from the providers’ perspective: opportunity for intervention development. Am J Hosp Palliat Care. 2015;32:137–43.

    Article  PubMed  Google Scholar 

  24. Yancu CN, Farmer DF, Leahman D. Barriers to hospice use and palliative care services use by African American adults. Am J Hosp Palliat Care. 2010;27:248–53.

    Article  PubMed  Google Scholar 

  25. Noh H, Schroepfer TA. Terminally ill African American elders’ access to and use of hospice care. Am J Hosp Palliat Care. 2015;32:286–97.

    Article  PubMed  Google Scholar 

  26. Welch LC, Teno JM, Mor V. End-of-life care in black and white: race matters for medical care of dying patients and their families. J Am Geriatr Soc. 2005;53:1145–53.

    Article  PubMed  Google Scholar 

  27. Smith-Howell ER, Hickman SE, Meghani SH, Perkins SM, Rawl SM. End-of-Life decision making and communication of bereaved family members of African Americans with serious illness. J Palliat Med. 2016;19:174–82.

    Article  PubMed  PubMed Central  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 

  29. Flaherty ML, Woo D, Haverbusch M, et al. Racial variations in location and risk of intracerebral hemorrhage. Stroke. 2005;36:934–7.

    Article  PubMed  Google Scholar 

  30. Cruz-Flores S, Rabinstein A, Biller J, et al. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:2091–116.

    Article  PubMed  Google Scholar 

  31. James ML, Grau-Sepulveda MV, Olson DM, et al. Insurance status and outcome after intracerebral hemorrhage: findings from get with the guidelines-stroke. J Stroke Cerebrovasc Dis. 2014;23:283–92.

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

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.

Funding

This study was supported by a research grant from the National Institute of Neurological Disorders (NINDS: U01-NS069763).

Author information

Author notes

  1. Cora H. Ormseth, Guido J. Falcone, Daniel Woo and Kevin N. Sheth have contributed equally to the manuscript.

Authors and Affiliations

  1. Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, New Haven, CT, 06510, USA

    Cora H. Ormseth, Guido J. Falcone, Sara D. Jasak, David M. Mampre, Audrey C. Leasure, Laura C. Miyares, David Y. Hwang & Kevin N. Sheth

  2. Departments of Anesthesiology and Neurology, Duke University, Durham, USA

    Michael L. James

  3. Departments of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, USA

    Fernando D. Testai

  4. Department of Neurology, University of Washington, Seattle, USA

    Kyra J. Becker & David L. Tirschwell

  5. Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, USA

    Carl D. Langefeld

  6. Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, USA

    Daniel Woo

Authors
  1. Cora H. Ormseth
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Guido J. Falcone
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sara D. Jasak
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David M. Mampre
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Audrey C. Leasure
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Laura C. Miyares
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. David Y. Hwang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Michael L. James
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Fernando D. Testai
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Kyra J. Becker
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. David L. Tirschwell
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Carl D. Langefeld
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Daniel Woo
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Kevin N. Sheth
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

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.

Corresponding author

Correspondence to Kevin N. Sheth.

Ethics declarations

Conflict of interest

All authors report no competing interests relevant to the manuscript.

Ethics Approval

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.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ormseth, C.H., Falcone, G.J., Jasak, S.D. et al. Minority Patients are Less Likely to Undergo Withdrawal of Care After Spontaneous Intracerebral Hemorrhage. Neurocrit Care 29, 419–425 (2018). https://doi.org/10.1007/s12028-018-0554-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-018-0554-4

Keywords

Search

Navigation