Effects of withdrawal of life-sustaining therapy on long-term neurological outcome after cardiac arrest - A multicentre matched cohort study.

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.