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. 2025 Mar 3;8(3):e251714.
doi: 10.1001/jamanetworkopen.2025.1714.

Recovery Potential in Patients After Cardiac Arrest Who Die After Limitations or Withdrawal of Life Support

Jonathan Elmer  1   2   3 , Patrick J Coppler  1 , Cecelia Ratay  1 , Alexis Steinberg  1   2   3 , Sara DiFiore-Sprouse  1 , Nicholas Case  1 , Baruch Fischhoff  4 , Maria De-Arteaga  5 , Alain Cariou  6 , Alejandro A Rabinstein  7 , Andrea O Rossetti  8 , Ankur A Doshi  1 , Bradley J Molyneaux  9 , Cameron Dezfulian  10 , Carolina B Maciel  11 , Christoph Leithner  12 , Cindy H Hsu  13 , Claudio Sandroni  14   15 , David M Greer  16 , David B Seder  17   18   19 , Francis X Guyette  1 , Fabio Silvio Taccone  20 , Hiromichi Naito  21 , Jasmeet Soar  22 , Jean-Baptiste Lascarrou  23 , Jerry P Nolan  24   25 , Karen G Hirsch  26 , Katherine M Berg  27 , Marion Moseby-Knappe  28 , Markus B Skrifvars  29 , Michael C Kurz  30 , Min Jung Kathy Chae  31 , Mypinder S Sekhon  32 , Nicholas J Johnson  33 , Pedro Kurtz  34 , Romergryko G Geocadin  35 , Sachin Agarwal  36 , Teresa L May  18   19 , Theresa M Olasveengen  37   38 , Clifton W Callaway  1 ; Optimizing Recovery Prediction After Cardiac Arrest (ORCA) Study Group
Collaborators, Affiliations

Recovery Potential in Patients After Cardiac Arrest Who Die After Limitations or Withdrawal of Life Support

Jonathan Elmer et al. JAMA Netw Open. .

Abstract

Importance: Understanding the relationship between patients' clinical characteristics and outcomes is fundamental to medicine. When critically ill patients die after withdrawal of life-sustaining therapy (WLST), the inability to observe the potential for recovery with continued aggressive care could bias future clinical decisions and research.

Objective: To quantify the frequency with which experts consider patients who died after WLST following resuscitated cardiac arrest to have had recovery potential if life-sustaining therapy had been continued.

Design, setting, and participants: This prospective cohort study included comatose adult patients (aged ≥18 years) treated following resuscitation from cardiac arrest at a single academic medical center between January 1, 2010, and July 31, 2022. Patients with advanced directives limiting critical care or who experienced cardiac arrest of traumatic or neurologic etiology were excluded. An international cohort of experts in post-arrest care based on clinical experience and academic productivity was identified. Experts reviewed the cases between August 24, 2022, and February 11, 2024.

Exposure: Patients who died after WLST.

Main outcome and measures: Three or more experts independently estimated recovery potential for each patient had life-sustaining treatment been continued, using a 7-point numerical ordinal scale. In the primary analysis, which involved the patient cases with death after WLST, a 1% or greater estimated recovery potential was considered to be clinically meaningful. In secondary analyses, thresholds of 5% and 10% estimated recovery probability were explored.

Results: A total of 2391 patients (median [IQR] age, 59 [48-69] years; 1455 men [60.9%]) were included, of whom 714 (29.9%) survived to discharge. Cases of uncertain outcome (1431 patients [59.8%]) in which WLST preceded death were reviewed by 38 experts who rendered 4381 estimates of recovery potential. In 518 cases (36.2%; 95% CI, 33.7%-38.7%), all experts believed that recovery potential was less than 1% if life-sustaining therapies had been continued. In the remaining 913 cases (63.8%; 95% CI, 61.3%-66.3%), at least 1 expert believed that recovery potential was at least 1%. In 227 cases (15.9%; 95% CI, 14.0%-17.9%), all experts agreed that recovery potential was at least 1%, and in 686 cases (47.9%; 95% CI, 45.3%-50.6%), expert estimates differed at this threshold.

Conclusions and relevance: In this cohort study of comatose patients resuscitated from cardiac arrest, most who died after WLST were considered by experts to have had recovery potential. These findings suggest that novel solutions to avoiding deaths based on biased prognostication or incomplete information are needed.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Elmer and Ratay, Mssrs Coppler and Case, and Mrs DiFiore-Sprouse reported receiving grants from the National Institute of Neurological Disorders and Stroke during the conduct of the study and grants from the National Heart, Lung, and Blood Institute outside the submitted work. Dr De-Arteaga reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Rabinstein reported participating on a clinical event committee with Boston Scientific and receiving advisory board fees from Shionogi, Chiesi, and Ceribell outside the submitted work. Dr Molyneaux reported having equity interest in Celdara Medical outside the submitted work. Dr Taccone reported receiving personal fees from Becton Dickinson and ZOLL Medical Corporation during the conduct of the study. Dr Lascarrou reported receiving personal fees from Masimo outside the submitted work. Dr Skrifvars reported receiving speaker fees from Bard Medical during the conduct of the study. Dr Johnson reported receiving grants from the National Institutes of Health and American Heart Association during the conduct of the study and advisory board fees from Neuroptics outside the submitted work. Dr Callaway reported receiving grants from the National Institute of Neurological Disorders and Stroke and National Heart, Lung, and Blood Institute during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Association of Clinical Characteristics and Treatments With Patient Outcomes for Making Rational Medical Decisions and Advancing Science
Dashed lines indicate counterfactual theoretical outcomes. Colors map between panels to show the same patients. WLST indicates withdrawal of life-sustaining therapy.
Figure 2.
Figure 2.. Flow Diagram for the Study Cohort
WLST indicates withdrawal of life-sustaining therapy.
Figure 3.
Figure 3.. Distribution of Expert Estimates
See this image and copyright information in PMC

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