Prognostic Language and Subsequent Code-Status Limitation After Acute Brain Injury: A Multidatabase Observational Study
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Purpose
Prognostic assessments after acute brain injury are largely narrative, and how prognostic language relates to subsequent care has not been measured at scale. We quantified where it is written and its association with a subsequent code-status limitation.
Materials and Methods
Multidatabase observational study of adults with acute brain injury or a related neurologic emergency, using MIMIC-IV (2008-2019; discharge summaries and radiology reports) and a timestamped MIMIC-III cohort (notes and code-status orders). The exposure was documented prognostic language; outcomes were its association with a subsequent full-code-to-limitation transition, note-stream location, and completeness of documented command-following relative to structured Glasgow Coma Scale (GCS) motor scores.
Results
Among 31,993 admissions (27,054 patients; median age, 69 years; 54.9% male), prognostic language in the timestamped cohort (MIMIC-III) was associated with a subsequent code-status limitation after multivariable adjustment (adjusted hazard ratio, 4.3; 95% CI, 2.9-6.5; unadjusted 14-day cumulative incidence, 40% vs 8.5%), including the comfort-measures component (3.9), a higher-risk subgroup (4.4), and after acute-physiology adjustment (4.1); the association was concentrated in the first 3 days. Non-prognostic severity language showed no comparable association (hazard ratios, 1.1-1.3). Prognostic language localized almost entirely to the narrative (4.9% of discharge summaries vs 0.015% of radiology reports); command-following was undocumented in 55.7% of summaries, and no final-24-hour GCS motor score was charted in 72.8%.
Conclusions
Documented prognostic language after acute brain injury was written in the narrative, not structured fields, and was associated with a subsequent code-status limitation after multivariable adjustment. This observational association cannot establish causation but warrants prospective study.
Key Points
Question
In routine records of acute brain injury, where is prognostic language written, and is it associated with a subsequent transition to a limited code status?
Findings
Across 31,993 admissions, prognostic language was detected in 4.9% of discharge summaries but almost never in radiology reports; in a timestamped cohort it was associated with a subsequent full-code-to-limitation transition after multivariable adjustment (hazard ratio, 4.3; 4.1 with added acute physiology), an association not seen for far more common non-prognostic severity text and concentrated in the first 3 days. This observational association cannot establish causation.
Meaning
Prognostic language lives in the treating team’s narrative and is closely coupled with subsequent code-status decisions, warranting prospective study.
