Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation
Hiromichi Naito,
Masaaki Sakuraya,
Takashi Hongo,
Hiroaki Takada,
Tetsuya Yumoto,
Takashi Yorifuji,
Toru Hifumi,
Akihiko Inoue,
Tetsuya Sakamoto,
Yasuhiro Kuroda,
Atsunori Nakao,
SAVE-J II Study Group
Affiliations
Hiromichi Naito
Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
Masaaki Sakuraya
Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital
Takashi Hongo
Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
Hiroaki Takada
Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center
Tetsuya Yumoto
Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
Takashi Yorifuji
Department of Epidemiology, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Science
Toru Hifumi
Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital
Akihiko Inoue
Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center
Tetsuya Sakamoto
Department of Emergency Medicine, Teikyo University School of Medicine
Yasuhiro Kuroda
Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University
Atsunori Nakao
Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Faculty of Medicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
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.
