Effects of withdrawal of life-sustaining therapy on long-term neurological outcome after cardiac arrest − A multicentre matched cohort study
Alice Lagebrant, Byung Kook Lee, Chun Song Youn, Claudio Sandroni, Jan Bělohlávek, Alain Cariou, Riccardo Carrai, Josef Dankiewicz, Hans Friberg, Anders Morten Grejs, Antonello Grippo, Christian Hassager, Janneke Horn, Matthias Hænggi, Janus Christian Jakobsen, Thomas Keeble, Hans Kirkegaard, Jesper Kjærgaard, Michaël Kuiper, Dong Hun Lee, Helena Levin, Gisela Lilja, Andreas Lundin, Niklas Nielsen, Mauro Oddo, Sang Hoon Oh, Kyu Nam Park, Tommaso Pellis, Chiara Robba, Christian Rylander, Seok Jin Ryu, Manoj Saxena, Maenia Scarpino, Claudia Schrag, Pascal Stammet, Christian Storm, Fabio Silvio Taccone, Matthew Thomas, Susann Ullén, Erik Westhall, Matt P. Wise, Paul J. Young, Tobias Cronberg, Marion Moseby‐Knappe
Abstract
PURPOSE: To assess the risk of self-fulfilling prophecy from withdrawal of life-sustaining therapy (WLST) in comatose cardiac arrest patients undergoing neuroprognostication. METHODS: Post-hoc multicentre study matching adults resuscitated from out-of-hospital cardiac arrests, in WLST-permitting cohorts (TTM and TTM2), and non-WLST-permitting cohorts (KORHN and ProNeCA). We matched patients in a 1:1 ratio based on a propensity score, assessing the risk of WLST due to a presumed poor neurological prognosis and criteria predictive of poor neurological outcome, as outlined in the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guidelines. Functional outcome was compared at six months. RESULTS: We included 1717 patients, of whom 497 (29 %) had WLST due to neurological criteria at a median of 143 h (IQR 108-177). 303 (61 %) patients with WLST retrospectively fulfilled ≥ 2 ERC/ESICM criteria predictive of poor outcome. No patients with ≥ 2 ERC/ESICM criteria had good functional outcome at six months, neither in the WLST cohort nor among the matched controls. One patient (0.3 %) with an indeterminate prognosis (≤1 ERC/ESICM criteria) had a good functional outcome in the WLST cohort versus 18-26 % of the matched controls. In exploratory weighted estimates, up to 18 % of patients with indeterminate prognosis may have survived with a good functional outcome, if WLST had not occurred. CONCLUSION: In patients with at least 2 ERC/ESICM criteria predictive of poor outcome, the risk of self-fulfilling prophecy from WLST was negligible. However, in patients with an indeterminate prognosis, the practice of WLST was associated with a lower likelihood of good functional outcome.