Semin Neurol 2017; 37(01): 081-087
DOI: 10.1055/s-0036-1595814
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Withdrawal of Life-Sustaining Therapy after Cardiac Arrest

Tobias Cronberg
1   Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
,
Michael Kuiper
2   Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
› Author Affiliations
Further Information

Publication History

Publication Date:
01 February 2017 (online)

Abstract

An increasing number of patients are successfully resuscitated from cardiac arrest (CA) and subsequently treated in an intensive care unit due to unconsciousness. Approximately half of these patients will die during the first weeks postarrest, typically after a determination of a poor neurologic prognosis and a decision to withdraw life-sustaining therapy (WLST). These decisions are guided by universal ethical principles. Neurologic prognostication, WLST, and functional outcome after CA are closely correlated, but routines vary between and within countries. Recent studies indicate that premature decisions to withdraw care may be common. This topical review will focus on the decision of WLST for patients remaining unconscious after CA, the guiding ethical principles, and the interaction with neurologic prognostication and outcome.

 
  • References

  • 1 Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T. The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 2013; 84 (3) 337-342
  • 2 Bouwes A, Binnekade JM, Kuiper MA , et al. Prognosis of coma after therapeutic hypothermia: a prospective cohort study. Ann Neurol 2012; 71 (2) 206-212
  • 3 Samaniego EA, Mlynash M, Caulfield AF, Eyngorn I, Wijman CA. Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia. Neurocrit Care 2011; 15 (1) 113-119
  • 4 Sprung CL, Cohen SL, Sjokvist P , et al; Ethicus Study Group. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003; 290 (6) 790-797
  • 5 Phua J, Joynt GM, Nishimura M , et al. Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med 2016; 42 (7) 1118-1127
  • 6 Dunne RB, Compton S, Zalenski RJ, Swor R, Welch R, Bock BF. Outcomes from out-of-hospital cardiac arrest in Detroit. Resuscitation 2007; 72 (1) 59-65
  • 7 Lindner TW, Søreide E, Nilsen OB, Torunn MW, Lossius HM. Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region. Resuscitation 2011; 82 (12) 1508-1513
  • 8 Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010; 81 (11) 1479-1487
  • 9 Deakin CD, Fothergill R, Moore F, Watson L, Whitbread M. Level of consciousness on admission to a Heart Attack Centre is a predictor of survival from out-of-hospital cardiac arrest. Resuscitation 2014; 85 (7) 905-909
  • 10 Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA. In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 2003; 56 (3) 247-263
  • 11 Carr BG, Kahn JM, Merchant RM, Kramer AA, Neumar RW. Inter-hospital variability in post-cardiac arrest mortality. Resuscitation 2009; 80 (1) 30-34
  • 12 Lemiale V, Dumas F, Mongardon N , et al. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med 2013; 39 (11) 1972-1980
  • 13 Laver S, Farrow C, Turner D, Nolan J. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 2004; 30 (11) 2126-2128
  • 14 Sandroni C, Adrie C, Cavallaro F , et al. Are patients brain-dead after successful resuscitation from cardiac arrest suitable as organ donors? A systematic review. Resuscitation 2010; 81 (12) 1609-1614
  • 15 Webb AC, Samuels OB. Reversible brain death after cardiopulmonary arrest and induced hypothermia. Crit Care Med 2011; 39 (6) 1538-1542
  • 16 Domínguez-Gil B, Haase-Kromwijk B, Van Leiden H , et al; European Committee (Partial Agreement) on Organ Transplantation. Council of Europe (CD-P-TO). Current situation of donation after circulatory death in European countries. Transpl Int 2011; 24 (7) 676-686
  • 17 Howell K, Grill E, Klein AM, Straube A, Bender A. Rehabilitation outcome of anoxic-ischaemic encephalopathy survivors with prolonged disorders of consciousness. Resuscitation 2013; 84 (10) 1409-1415
  • 18 Fugate JE, Wijdicks EF, White RD, Rabinstein AA. Does therapeutic hypothermia affect time to awakening in cardiac arrest survivors?. Neurology 2011; 77 (14) 1346-1350
  • 19 Mulder M, Gibbs HG, Smith SW , et al. Awakening and withdrawal of life-sustaining treatment in cardiac arrest survivors treated with therapeutic hypothermia*. Crit Care Med 2014; 42 (12) 2493-2499
  • 20 Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. Oxford, UK: Oxford University Press; 2013
  • 21 Gillon R. Medical ethics: four principles plus attention to scope. BMJ 1994; 309 (6948): 184-188
  • 22 Bossaert LL, Perkins GD, Askitopoulou H , et al; ethics of resuscitation and end-of-life decisions section Collaborators. European Resuscitation Council guidelines for resuscitation 2015: section 11. The ethics of resuscitation and end-of-life decisions. Resuscitation 2015; 95: 302-311
  • 23 Hart JL, Harhay MO, Gabler NB, Ratcliffe SJ, Quill CM, Halpern SD. Variability among US intensive care units in managing the care of patients admitted with preexisting limits on life-sustaining therapies. JAMA Intern Med 2015; 175 (6) 1019-1026
  • 24 Langhelle A, Nolan J, Herlitz J , et al; 2003 Utstein Consensus Symposium. Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: the Utstein style. Resuscitation 2005; 66 (3) 271-283
  • 25 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872): 81-84
  • 26 Sandroni C, Cavallaro F, Callaway CW , et al. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 1: patients not treated with therapeutic hypothermia. Resuscitation 2013; 84 (10) 1310-1323
  • 27 Sandroni C, Cavallaro F, Callaway CW , et al. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Resuscitation 2013; 84 (10) 1324-1338
  • 28 Smith CM. Origin and uses of primum non nocere--above all, do no harm!. J Clin Pharmacol 2005; 45 (4) 371-377
  • 29 Geurts M, Macleod MR, van Thiel GJ, van Gijn J, Kappelle LJ, van der Worp HB. End-of-life decisions in patients with severe acute brain injury. Lancet Neurol 2014; 13 (5) 515-524
  • 30 Kim YJ, Ahn S, Sohn CH , et al. Long-term neurological outcomes in patients after out-of-hospital cardiac arrest. Resuscitation 2016; 101: 1-5
  • 31 van Erp WS, Lavrijsen JC, Vos PE, Bor H, Laureys S, Koopmans RT. The vegetative state: prevalence, misdiagnosis, and treatment limitations. J Am Med Dir Assoc 2015; 16 (1) 85.e9-85.e14
  • 32 Nielsen N, Hovdenes J, Nilsson F , et al; Hypothermia Network. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2009; 53 (7) 926-934
  • 33 Hasselqvist-Ax I, Herlitz J, Svensson L. Early CPR in out-of-hospital cardiac arrest. N Engl J Med 2015; 373 (16) 1573-1574
  • 34 Hallstrom AP, Ornato JP, Weisfeldt M , et al; Public Access Defibrillation Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med 2004; 351 (7) 637-646
  • 35 Mancini ME, Diekema DS, Hoadley TA , et al. Part 3: Ethical issues: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132 (18) (Suppl. 02) S383-S396
  • 36 Levin PD, Sprung CL. Withdrawing and withholding life-sustaining therapies are not the same. Crit Care 2005; 9 (3) 230-232
  • 37 Pusswald G, Fertl E, Faltl M, Auff E. Neurological rehabilitation of severely disabled cardiac arrest survivors. Part II. Life situation of patients and families after treatment. Resuscitation 2000; 47 (3) 241-248
  • 38 Azoulay E, Metnitz B, Sprung CL , et al; SAPS 3 investigators. End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 2009; 35 (4) 623-630
  • 39 Laureys S, Celesia GG, Cohadon F , et al; European Task Force on Disorders of Consciousness. Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Med 2010; 8: 68
  • 40 Epker JL, de Groot YJ, Kompanje EJ. Respiratory support withdrawal in intensive care units: international differences stressed and straightened!. Crit Care 2011; 15 (2) 405 , author reply 405
  • 41 Nielsen N, Wetterslev J, al-Subaie N , et al. Target temperature management after out-of-hospital cardiac arrest—a randomized, parallel-group, assessor-blinded clinical trial--rationale and design. Am Heart J 2012; 163 (4) 541-548
  • 42 Dragancea I, Horn J, Kuiper M , et al; TTM Trial Investigators. Neurological prognostication after cardiac arrest and targeted temperature management 33°C versus 36°C: results from a randomised controlled clinical trial. Resuscitation 2015; 93: 164-170
  • 43 Perman SM, Kirkpatrick JN, Reitsma AM , et al. Timing of neuroprognostication in postcardiac arrest therapeutic hypothermia*. Crit Care Med 2012; 40 (3) 719-724
  • 44 Albaeni A, Chandra-Strobos N, Vaidya D, Eid SM. Predictors of early care withdrawal following out-of-hospital cardiac arrest. Resuscitation 2014; 85 (11) 1455-1461
  • 45 Elmer J, Torres C, Aufderheide TP , et al; Resuscitation Outcomes Consortium. Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest. Resuscitation 2016; 102: 127-135
  • 46 Grossestreuer AV, Abella BS, Leary M , et al. Time to awakening and neurologic outcome in therapeutic hypothermia-treated cardiac arrest patients. Resuscitation 2013; 84 (12) 1741-1746
  • 47 Gold B, Puertas L, Davis SP , et al. Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early?. Resuscitation 2014; 85 (2) 211-214
  • 48 Nolan JP, Soar J, Cariou A , et al; European Resuscitation Council; European Society of Intensive Care Medicine. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care. Intensive Care Med 2015; 41 (12) 2039-2056
  • 49 Kuiper MA. Dying: domain of critical care medicine?. Crit Care Med 2012; 40 (1) 316-317
  • 50 Kuiper MA, Whetstine LM, Holmes JL , et al. Euthanasia: a word no longer to be used or abused. Intensive Care Med 2007; 33 (3) 549-550
  • 51 Quill TE. Terri Schiavo--a tragedy compounded. N Engl J Med 2005; 352 (16) 1630-1633
  • 52 Edwards MJ. Opioids and benzodiazepines appear paradoxically to delay inevitable death after ventilator withdrawal. J Palliat Care 2005; 21 (4) 299-302
  • 53 Epker JL, Bakker J, Kompanje EJ. The use of opioids and sedatives and time until death after withdrawing mechanical ventilation and vasoactive drugs in a Dutch intensive care unit. Anesth Analg 2011; 112 (3) 628-634