Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation

Abstract

Background Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR. Methods We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined. Results We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p < 0.001). Primary cerebral disorders as cause of cardiac arrest and higher severity of illness at intensive care unit admission were associated with WLST decisions. Conclusion For approximately one-third of ECPR/OHCA patients, WLST was decided during admission, mainly because of perceived unfavorable neurological prognoses. Decisions and neurological assessments for ECPR/OHCA patients need further analysis.

Protocol for immunophenotyping out-of-hospital cardiac arrest patients

“…However, unlike many other illnesses, a major cause of in-hospital death is WLST by surrogate decision-makers (e.g., family members) when the likely neurological prognosis is not within the patient’s goals of care. 24 Neurological prognostication is most commonly driven by the clinical neurological exam, brain imaging (i.e., magnetic resonance imaging [MRI]), electro-encephalogram (EEG), and somatosensory evoked potentials (SSEP).…”

Association between pupillary examinations and prognosis in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective multicentre cohort study

“…Early prognostication is difficult because of persistently reduced consciousness and haemodynamic instability in severely ill cardiac arrest survivors [ 5 ]. However, 30–50% of ECPR patients have reported experiencing early withdrawal of life-sustaining therapy within 72 h, mainly because of the perceived poor neurological prognosis [ 6 , 7 ]. Errors in prognostication can have significant consequences.…”

Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study

“…Indeed, a large retrospective study of ECPR in Japan, a leading country in the field of ECPR, revealed that decisions to withhold or withdraw life-sustaining therapy were most frequently made on the first day, with a median decision time of 2 days following admission to the ICU. Importantly, the perceived unfavorable neurological prognosis was the primary reason for the withhold or withdraw life-sustaining therapy decision [7]. In Japan, the legal diagnosis of brain death while on extracorporeal membrane oxygenation (ECMO) was not allowed until recent guideline amendments [8].…”