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Out-of-Hospital Cardiac Arrest (OHCA) is a leading cause of mortality worldwide. Amongst patients who achieve return of spontaneous circulation and are admitted to hospital, most will die from the effects of brain injury. Withdrawal of Life Sustaining Treatments (WLST) is the most common means of death, and current guidelines recommend WLST only after formal neuroprognostication, and after 72 hours. We aimed to determine the incidence and characteristics associated with WLST compared with no WLST in comatose patients following OHCA.
Methods and Results
Patients admitted to hospital after non-traumatic OHCA between 2012-2019 who subsequently died were studied in a multicentred, retrospective cohort study across three Toronto academic hospitals. Data including baseline demographics, pre-existing medical comorbidities, in-hospital investigations and interventions, medical complications in hospital, goals of care discussions and mode of death were collected. WLST was defined as having documentation that medical interventions were withheld or discontinued (excluding formal declaration of brain death). Of the 130 included patients, 81 received WLST and 49 did not. Demographic and clinical characteristics are outlined in Table 1. Both groups were similar in terms of their pre-existing cardiac and non-cardiac comorbidities, although patients not receiving WLST had greater evidence of multiorgan failure and less often documented goals of care discussions. In those that received WLST, 82% of cases were due to concerns for poor neurologic prognosis with the remainder due to non-neurologic related prognosis or previously expressed wishes regarding interventions. Nearly half of WLST (45%) were < 72 hours from presentation. In patients not receiving WLST, 37% had formal declaration of brain death and the remainder died of medical complications.
In this exploratory analysis, many comatose patients receive WLST due to concerns of poor neurologic prognosis without formal declaration of brain death and many of these cases occur < 72 hours. Physicians may over-estimate poor outcomes in this population.