Predicting Outcome From Hypoxic-Ischemic Coma-Reply

In Reply.—  We were aware of the possibility that a self-fulfilling prophecy might have influenced our data. Although we did not communicate findings to physicians in our hospitals, Hart and colleagues correctly point out that "conventional" wisdom could have led to premature withdrawal of care in some patients. We think, however, that this did not exert a major influence on our results.¹To estimate the magnitude of this potential problem, we have reanalyzed the data for patients with preserved or absent pupillary light reflexes on the initial examination. One would expect patients with absent pupillary light reflexes to die more rapidly than those with preserved reflexes for at least two reasons: (1) a poorer clinical condition and (2) the possibility of premature withdrawal of care. Fifty-two of 53 patients with absent pupillary reflexes died within the first month, and 112 of 157 patients with preserved reflexes also died within