Study examines time to death, predictive factors after palliative extubation

After palliative extubation, mortality rates were 43% at 12 hours, 56% at 24 hours, 68% at 72 hours, and 79% at 96 hours.

Low systolic blood pressure and high comorbidities may predict death after palliative extubation, a new study found.

Researchers used data from 148 patients (mean age 78 years; 60% female) who, between September 2010 to August 2013, had undergone palliative extubation in any clinical unit of a 500-bed ethnically diverse community hospital in Queens, N.Y. Results were published in the June issue of Critical Care Medicine.

One-quarter of patients had tracheostomy on admission, 16% were ventilator-dependent, and the top diagnostic categories were sepsis (47%) and primary respiratory failure (22%). The main outcome measures were in-hospital mortality rate, survival rate to discharge, time from palliative extubation to death, and place of discharge for surviving patients.

Of the 148 patients, 114 (77%) died in the hospital, and 34 (23%) were discharged alive, primarily to hospice or nursing home settings. Median survival was 8.9 hours (range, 4 minutes to 7 days) among those who died in the hospital, and for those surviving to discharge, median time to discharge was about 4 days. After palliative extubation, mortality rates were 43% at 12 hours, 56% at 24 hours, 68% at 72 hours, and 79% at 96 hours. Age (<65 or ≥65 years) was not significantly associated with early death (defined as death within 24 hours).

Charlson Comorbidity Index (CCI) scores showed a U-shaped link with death. Patients with high (CCI=6 to 13) comorbidities or no (CCI=0) comorbidities but with a single devastating event had an 83% higher risk of death than those with moderate (CCI=1 to 5) comorbidities (P=0.01). Median survival was longer in patients with normal blood pressure than in patients with hypotension (19 vs. 9 hours), and patients with systolic blood pressure below 90 mm Hg had a 2.5-times higher risk of death (P=0.01).

The study authors noted limitations to the study, such as its retrospective single-center design, the high percentage of chronic ventilator patients in the cohort, and the potential difficulty of using the CCI and systolic blood pressure to prognosticate mortality risk at the bedside. “In a society where the population is aging, we note that age itself was not a significant factor or predictor in mortality versus survival after palliative extubation,” they wrote. “More important is the concept of ‘physiologic age,’ as evidenced by number of comorbidities and hypotension.”