Decision of therapy termination in cardiac surgery

Objectives: Death from cardiocirculatory failure may be delayed almost without limitation using advanced technologies, e.g. extracorporeal membrane oxygenation (ECMO). However, life support therapy, surgery or resuscitation should be limited to patients with a potential for survival. Thus, the time point of in-hospital death of patients after cardiac surgery may be determined by a medical decision more frequently than in other fields. The aim of this study is to analyze the decision making process associated with death of patients after cardiac surgery at our institution.

Methods: From 08/2009 until 03/2011, 104 patients died after cardiac surgery at our institution. Medical records of those patients were retrospectively analyzed.

Results: Patients were categorized into following 4 groups; intraoperative death (group 1; n=7, 3 males, mean age 79 y.o.), therapy withdraw/withhold due to continuous deterioration (group 2; n=65, 42 males, mean age 72 y.o., mean postoperative hospital stay (PHS) 14d.), therapy withdraw/withhold due to a marginal clinical status (group 3; n=20, 14 males, mean age 68 y.o., mean PHS 16d.) and cessation of resuscitation (group 4; n=12, 9 males, mean age 70 y.o., mean PHS 17d.). ECMO was applied in 1, 17, 3 and 2 patients in group 1, 2, 3 and 4, respectively. In group 2 and 3, a “therapy withdraw” was done with stopping of cathecholamine administration, discontinuation of external pacemaker stimulation, reduction of respiratory oxygen fraction to 21% and cessation of ECMO when ECMO therapy was applied. An extubation of endothorachial tube was not done in any patient. With the decision of “therapy withhold” of the dosage of cathecholamines and the oxygen fraction were freezed as those at the time of decision and no more transfusion was done. In all the cases in group 2 and 3, familial member were involved in the decision making process. In group 2, therapy was withdrawn in 32 patients, withheld in 33 patients. In group 3, therapy was withdrawn in 19 patients and withheld in one patient.

Conclusions: In this analysis, the time of death was related to a decision making in all the patients after cardiac surgery. Therapy withdraw was more common in patients with a marginal status without recovery tendency than in patients with continuous deterioration.