Treatment-Limiting Decisions in Neurointensive Care: Withholding or Withdrawal of Life-Sustaining Measures

Background: Treatment-limiting decisions (TLDs) in neurointensive care are frequently reported with no distinction between withholding and withdrawal of treatment. We investigated the proportion of patients subjected to withholding and withdrawal of life-sustaining treatment during neurointensive care, and the association with mortality. Methods: This retrospective observational cohort study included all adult (≥ 18 years) neurocritically ill patients admitted to the neurointensive care unit (neuro-ICU), Rigshospitalet, Denmark, for a primary CNS injury during the period from July 2019 to February 2022. Patients were categorised into the following three groups: full treatment, withholding, or withdrawal of life-sustaining treatment. We compared 30-day all-cause mortality of the three groups by a Cox proportional-hazards model and by calculating the mean restricted survival time at 30 days. Results: Of 694 eligible patients, a decision to withhold or withdraw treatment was made for 50 (7.2%) and 124 (17.9%) patients, respectively. Patients subjected to withholding were older and had a higher Charlson Comorbidity Index, whereas those subjected to withdrawal had a lower Glasgow Coma Score (GCS) and a higher Acute Physiology and Chronic Health Evaluation II score. While the primary neurological injury was the main reason for the treatment-limiting decision, and comorbidity contributed in both groups, a history of cardiac arrest was also stated as a reason for withdrawing, and non-neurological injury as a reason for withholding therapy. The 30-day case fatality ratio was 32%, 98% and 8.1% for patients subjected to withholding, withdrawal and full treatment, respectively, corresponding to a mean restricted survival time at 30 days of 24 (95% CI, 21–27), 10.0 (8.2–12) and 29 (28, 29) days. Conclusion: In this study, TLDs were made in one out of four neuro-ICU patients. Furthermore, neurocritically ill patients subjected to withholding treatment had markedly higher survival than those subjected to withdrawal. Editorial Comment: In this assessment of treatment-limiting decisions in neuro-intensive care cases, the authors present how withholding escalating ICU treatment can occur in case conditions that differ from those where active ICU treatment is withdrawn.