Original Investigation
Critical Care Medicine
March 25, 2025
Recovery Potential in Patients After Cardiac Arrest Who Die After Limitations or Withdrawal of Life Support
Jonathan Elmer, Patrick J. Coppler, Cecelia Ratay, et al
JAMA Netw Open. 2025;8(3):e251714. doi:10.1001/jamanetworkopen.2025.1714
Question How often do experts believe that there was recovery potential in patients who had limitations or withdrawal of life-sustaining therapy (WLST) after resuscitation from cardiac arrest?
Findings In this cohort study of 2391 comatose survivors of cardiac arrest, all cases of patients who died after WLST (1431 [59.8%]) were evaluated. Upon independent review by 38 international experts, 913 patients (63.8%) who died after WLST were believed to have had a chance of recovery had life-sustaining therapy been continued.
Meaning These findings suggest that pessimistic clinical impressions and treatment decisions may perpetuate therapeutic nihilism and biased research.
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.
