Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies

Background: Withdrawal of support in patients with severe brain injury inva riably leads to death. Preconceived notions about futility of care in patie nts with intracerebral hemorrhage (ICH) may prompt withdrawal of support, a nd modeling outcome in patient populations in whom withdrawal of support oc curs may lead to self-fulfilling prophecies. Methods: Subjects included con secutive patients with supratentorial ICH. Radiographic characteristics of the hemorrhage, clinical variables, and neurologic outcome were assessed. A ttitudes about futility of care were examined among members of the departme nts of neurology and neurologic surgery through a written survey and case p resentations. Results: There were 87 patients with supratentorial ICH; over all mortality was 34.5% (30/87). Mortality was 66.7% (18/27) in patients wi th Glasgow Coma Score less than or equal to8 and ICH volume >60 cm(3). Medi cal support was withdrawn in 76.7% (23/30) of patients who died.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 predictin g outcome negated the predictive value of all other variables. Patients und ergoing surgical decompression were unlikely to have support withdrawn, and surgery was less likely to be performed in older patients (p < 0.01) and p atients with left hemispheric hemorrhage (p = 0.04). Survey results suggest ed that practitioners tend to be overly pessimistic in prognosticating outc ome 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 traditiona lly "poor outcome" categories can have a reasonable neurologic outcome when treated aggressively.