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This study examined 3,641 cardiac arrest patients across 161 ICUs to determine whether high predicted mortality scores (APACHE IVa) reliably identify patients who cannot achieve favorable recovery. While favorable discharge (to home or rehabilitation) decreased from 78.9% in the lowest-risk patients to 4.1% in the highest-risk group, even among patients with predicted mortality above 90%, 3.2% still achieved favorable outcomes. No patient subgroup had a statistically certain rate of favorable discharge below 5%, meaning some patients recovered well even when predictions suggested very low survival chances.
Why it matters
These findings challenge the use of general ICU mortality prediction scores alone for making withdrawal-of-care decisions after cardiac arrest. The results suggest that even patients with very high predicted mortality retain some possibility of meaningful recovery, which has important implications for end-of-life decision-making in intensive care settings.
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⚠️ Preprint – Noch nicht peer-reviewed
Dieser Artikel wurde noch nicht von unabhängigen Experten begutachtet. Die Ergebnisse sind vorläufig und sollten mit Vorsicht interpretiert werden.
Aim: General ICU severity scores predict hospital mortality across heterogeneous populations, not recovery within one diagnosis. We described favourable discharge across the range of APACHE IVa-predicted hospital mortality after cardiac arrest, and tested whether any bedside subgroup fell below a pre-specified benchmark. Methods: Observational cohort of 3,641 first ICU admissions in 161 eICU hospitals with a cardiac-arrest diagnosis documented within 24 hours. The exposure was APACHE IVa-predicted hospital mortality; the outcome was favourable discharge (home or rehabilitation), a functional-outcome proxy. Fourteen bedside subgroups were pre-specified; the benchmark required an upper 95% bound below 5%. Results: Favourable discharge occurred in 1,039 (28.5%), falling from 78.9% in the lowest predicted-mortality decile to 4.1% in the highest (trend z, -27.2; P < 0.001). Among 2,139 patients with predicted mortality at or above 50%, 301 (14.1%; 95% CI, 12.6 to 15.6) had a favourable discharge; among 281 at or above 90%, 9 (3.2%) did. No subgroup had an upper 95% bound below 5%; the lowest was 8 of 264 (3.0%; 95% CI, 1.3 to 5.9). At a more permissive 10% benchmark, two qualified. Among 1,961 not obeying commands, 263 (13.4%) had a favourable discharge. Discrimination did not differ detectably between unfavourable functional outcome (AUROC 0.789) and in-hospital death (0.774; P = 0.078). Conclusion: Favourable discharge declined as predicted mortality rose but remained observable at the highest risk levels, and no pre-specified subgroup was bounded below 5%. A general ICU mortality estimate is not on its own evidence that a favourable outcome is absent.