***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objectives : Withdrawal of life-sustaining therapy may lead to premature limitations of life-saving treatments among patients with intracranial hemorrhage , representing a self-fulfilling prophecy . We aim ed to determine whether our algorithm for the withdrawal of life-sustaining therapy decision would accurately identify patients with a high probability of poor outcome , despite aggressive treatment . Design : Retrospective analysis of prospect ively collected data . Setting : Tertiary-care Neuro-ICU . Patients : Intraparenchymal , subdural , and subarachnoid hemorrhage patients . Interventions : Baseline demographics , clinical status , and hospital course were assessed to determine the predictors of in-hospital mortality and 12-month death/severe disability among patients receiving maximal therapy .  Multivariable logistic regression models developed on maximal therapy patients were applied to patients who underwent withdrawal of life-sustaining therapy to predict their probable outcome had they continued maximal treatment . A validation cohort of propensity score – matched patients was identified from the maximal therapy cohort , and their predicted and actual outcomes compared . Measurements and Main Results : Of 383 patients enrolled , there were 128 subarachnoid hemorrhage ( 33.4 % ) , 134 subdural hematoma ( 35.0 % ) , and 121 intraparenchymal hemorrhage ( 31.6 % ) . Twenty-six patients ( 6.8 % ) underwent withdrawal of life-sustaining therapy and died , 41 ( 10.7 % ) continued maximal therapy and died in hospital , and 316 ( 82.5 % ) continued maximal therapy and survived to discharge . The median predicted probability of in-hospital death among withdrawal of life-sustaining therapy patients was 35 % had they continued maximal therapy , whereas the median predicted probability of 12-month death/severe disability was 98 % . In the propensity-matched validation cohort , 16 of 20 patients had greater than or equal to 80 % predicted probability of death/severe disability at 12 months , matching the observed outcomes and supporting the strength and validity of our prediction models . Conclusions : The withdrawal of life-sustaining therapy decision may contribute to premature in-hospital death in some patients who may otherwise have been expected to survive to discharge . However , based on probability models , nearly all of the patients who underwent withdrawal of life-sustaining therapy would have died or remained severely disabled at 12 months had maximal therapy been continued . Withdrawal of life-sustaining therapy may not represent a self-fulfilling prophecy Objective : To study the impact of neurologic prognostication on the decision to withdraw life-sustaining therapies ( LST ) in comatose patients resuscitated after cardiac arrest . Methods : The authors prospect ively studied a consecutive series of post-resuscitation comatose patients referred for neurologic prognostication at a single center for 4 years . For most patients , neurologic prognostication was not sought due to early death or rapid return to consciousness . Prognostication was based on Glasgow Coma Score ( GCS ) and Brainstem Reflex Score ( BRS ) , with EEG and cortical evoked potentials ( CEP ) , which were grade d as benign , uncertain , and malignant . The outcomes were as follows : survivors ( Group S ) , brain or cardiac death ( Group D ) , and death from withdrawal of life sustaining therapy ( Group W ) . In Group W , the time interval to withdrawal of LST was analyzed by EEG and CEP grade s. Results : Of 58 patients studied , 10 were in Group S , 8 in Group D , and 40 in Group W. Initial median GCS and BRS was similar for all groups with significant improvement noted in Group S , but not in Group D or Group W. In Group W , CEP grade correlated with the median duration of continued therapy before a decision to withdraw LST : 7 days for benign CEP , 2 days for uncertain CEP , and 1 day for malignant CEP , p = 0.0004 . Conclusion : In patients with poor neurologic recovery early after resuscitation from cardiac arrest , physicians appear to use the cortical evoked potential grade to estimate prognosis . Cortical evoked potential grade correlated with the waiting time until life sustaining therapies were withdrawn after no improvement in neurologic examination was seen Background Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage ( aSAH ) . We assessed admission factors impacting decisions to withdraw treatment after aSAH . Methods Prospect ively collected data of aSAH patients admitted to our institution between 1991 and 2009 were review ed . Patients given comfort care measures were identified , including early withdrawal of treatment ( < 72 h after admission ) . Independent predictors of treatment withdrawal were assessed with multivariable analysis . Results The study included 1,134 patients , of whom 72 % were female , 58 % white , and 38 % black or African-American . Mean age was 52.5 ± 14.0 years . In-hospital mortality was 18.3 % . Of the 207 patients who died , treatment was withdrawn in 72 ( 35 % ) and comfort measures instituted early in 31 ( 15 % ) . Among patients who died , WOLST was associated with older age ( 63.6 ± 14.2 years , WOLST vs. 55.6 ± 13.7 years , no WOLST , p < 0.001 ) ; GCS score < 8 ( 62 % of WOLST vs. 44 % with no WOLST , p = 0.010 ) ; HH > 3 ( 72 % of WOLST vs. 53 % with no WOLST , p = 0.008 ) ; and hydrocephalus ( 81 % of WOLST vs. 63 % with no WOLST , p = 0.009 ) . Independent predictors of WOLST were poorer Hunt and Hess grade ( AOR 1.520 , 95 % CI 1.160–1.992 , p = 0.002 ) and older age ( AOR 1.045 , 95 % CI 1.022–1.068 , p < 0.001 ) with the latter also impacting early WOLST decisions . Conclusions Older age and poor clinical grade on presentation predicted WOLST , and age predicted decisions to withdraw treatment earlier following aSAH . While based on prognosis , and in some cases patient wishes , this may also constitute a self-fulfilling prophecy in others Objective : Many intensive care unit ( ICU ) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker , yet little is known about the decision-making practice s for these patients . We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them . Design : Prospect i ve , observational cohort study . Patients and Setting : Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004 . Measurements : Attending physicians completed a question naire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker . Main Results : Of the 303 patients admitted during the study period , 49 ( 16 % ; 95 % confidence interval [ CI ] , 12–21 % ) lacked decision-making capacity and a surrogate during the entire ICU stay . Compared with all other ICU patients , these patients were more likely to be male ( 88 % vs. 69 % ; p = .002 ) , white ( 42 % vs. 23 % ; p = .028 ) , and ≥65 yrs old ( 29 % vs. 13 % ; p = .007 ) . Physicians considered withholding or withdrawing treatment from 37 % ( 18 ) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker . For 56 % ( 10 ) of these 18 patients , the opinion of another attending physician was obtained ; for 33 % ( 6 of 18 ) , the ICU team made the decision independently , and for 11 % ( 2 of 18 ) , the input of the courts or the hospital ethics committee was obtained . Overall , 27 % of deaths ( 13 of 49 ) during the study period were in incapacitated patients who lacked a surrogate ( 95 % CI , 15–41 % ) . Conclusions : Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker . Decisions to limit life support were generally made by physicians without judicial or institutional review . Further research and debate are needed to develop optimal decision-making strategies for these difficult cases Withdrawal of care has increased in recent years as the population older than 65 years of age has increased . We sought to investigate the impact of this decision on our mortality rate . We retrospectively review ed a prospect ively collected data base to determine the percentage of cases in which care was actively withdrawn . Neurologic injury as the cause for withdrawal , age of the patient , number of days to death , number of cases thought to be treatment failures , and the reason for failure were analyzed . Between January 2008 and December 2012 , there were 536 trauma service deaths ; 158 ( 29.5 % ) had care withdrawn . These patients were 67 ( 6 18.5 ) years old and neurologic injury was responsible in 63 per cent ( 6 5.29 % ) . Fifty-two per cent of the patients died by Day 3 ; 65 per cent by Day 5 ; and 74 per cent Day 7 . A total of 22.7 per cent ( 6 7.9 % ) could be considered a treatment failure . Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent . Trauma center mortality calculation does not account for care withdrawn . Treating an active , aging population , with advance directives , requires method ologies that account for such decision-making when determining mortality rates Objectives : To characterize the prevalence of withdrawal of life-sustaining treatment , as well as the time to awakening , short-term neurologic outcomes , and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia .  Design : Single center , prospect i ve observational cohort study of consecutive patients with out-of-hospital cardiopulmonary arrests . Setting : Academic tertiary care hospital and level one trauma center in Minneapolis , MN . Patients : Adults with witnessed , nontraumatic , out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU . Interventions : None . Measurements and Main Results : The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period . One hundred eighteen patients ( 77 % ) were treated with therapeutic hypothermia . The mean age was 59 years , 104 ( 68 % ) were men , and 83 ( 54 % ) had an initial rhythm of ventricular tachycardia or fibrillation . Only eight of all 78 patients ( 10 % ) who died qualified as brain dead ; and 81 % of all patients ( 63 of 78 ) who died did so after withdrawal of life-sustaining treatment . Twenty of 56 comatose survivors ( 32 % ) treated with hypothermia who awoke ( as defined by Glasgow Motor Score of 6 ) and had good neurologic outcomes ( defined as Cerebral Performance Category 1–2 ) did so after 72 hours . Conclusions : Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia . Larger multicenter prospect i ve studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia . These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death In some intensive care units ( ICUs ) , fewer patients who die now undergo attempts at cardiopulmonary resuscitation ( CPR ) , and many more have life support actively withdrawn prior to death than did a decade ago . To determine the frequency of withdrawal of life support , we contacted every American postgraduate training program with significant clinical exposure to critical care medicine , asking them prospect ively to classify patients who died into one of five mutually exclusive categories . We received data from 131 ICUs at 110 institutions in 38 states . There were 6,303 deaths , of which 393 patients were brain dead . Of the remaining 5,910 patients who died , 1,544 ( 23 % ) received full ICU care including failed cardiopulmonary resuscitation ( CPR ) ; 1,430 ( 22 % ) received full ICU care without CPR ; 797 ( 10 % ) had life support withheld ; and 2,139 ( 38 % ) had life support withdrawn . There was wide variation in practice among ICUs , with ranges of 4 to 79 % , 0 to 83 % , 0 to 67 % , and 0 to 79 % in these four categories , respectively . Variation was not 
    Output:
    
Based on several large , multicenter studies , there was a trend toward a higher frequency of limitation of LST  over time .
However , there is large variability between ICUs in the proportion of patients with limitations and on the proportion of deaths preceded by a limitation .
Increases in the frequency of limitations of LST  over time suggests changing attitudes about aggressive end-of-life-care .
Limitations are more common for patients with worse premorbid health and greater ICU illness severity .
While some differences in the frequency of limitations of LST  may be explained by personal factors such as race , there is unexplained wide variability between units