Editorials

Poor survival after cardiac arrest resuscitation: A self-fullling prophecy or biologic destiny?*
ignicant progress has been made in resuscitation science, with better chest compression, use of automated debrillators (1, 2), and in postresuscitation care with therapeutic hypothermia and comprehensive critical care (3, 4). Disappointingly, however, the overall survival to discharge remains dismally low at 9.6% for out-of-hospital cardiac arrest and 17% for in-hospital arrest (57). As we try to look for opportunities to further improve outcomes of patients at the bedside, study cohorts in clinical trials, and the population in general, one area that has escaped a focused approach is end-of-life decisions in the intensive care unit. These practices cover issues relating to the dying patient and include the limitation of care with do-not-attempt resuscitation status and the enactment of withdrawal of life-sustaining therapies. Implicit in the care of these critically ill patients is the matter of neurologic assessment, both with regard to concurrent validity and to prognosis, that has a direct impact on treatment decisions and outcome (8). In this issue of Critical Care Medicine, Perman and colleagues (9) bring forward some important and controversial issues on end-of-life care in critical care in a retrospective study of 55 consecutive patients treated with hypothermia after cardiac arrest resuscitation. Looking at the timing when prognosis was assigned, the authors found that 57% (28 of 55) of their cohort were given a poor or grave prognosis while they were still actively being cooled, or within 15 hrs after hypothermia when they were rewarmed. The early

*See also p. 719. Key Words: cardiac arrest; cardiopulmonary resuscitation; hypothermia; mortality; outcome; prognosis; withdrawal of life support Dr. Geocadin is supported, in part, by an NIH grant (R01-HC071568). Drs. Peberdy and Lazar have not disclosed any potential conicts of interest. Copyright 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3182410146

poor prognosis was assigned by the primary medical service in 75% and by a neurology consultant in 25% of cases. Of these 28 patients, 18 (64%) were assigned poor prognosis at the time that they were receiving sedating and paralytic drugs, and actively under hypothermia therapy. Subsequently, eight survived and 20 died. Of the eight survivors, six had good outcomes (cerebral performance category 1 or 2) and two had poor outcome (cerebral performance category 3 or 4), demonstrating weak predictive validity of the early poor prognosis. A rich literature on prognostication for neurologic outcome after cardiac arrest has led to new consensus statements (5, 10) and updated practice parameters (11). Of all the factors studied, it has been established that neurologic status, as reected by the bedside neurologic examination and neurologic-based testing after resuscitation, is the most reliable predictor of functional outcome. As pointed out by Perman et al (9), however, these neuro-based prognostic paradigms have been not been thoroughly validated in patients treated with hypothermia. The cornerstone of central nervous system evaluation continues to be a wellexecuted neurologic examination and testing (11, 12). It is critical, however, that assessment be undertaken in conditions that reect the true neurologic status of the patient. Any factor outside of the primary hypoxic-ischemic injury that will confound neurologic assessment has to be corrected and assessment delayed until the mitigation of such factors. Of particular relevance to Perman et al, the assignment of poor prognosis while the patient is still actively being treated with hypothermia and receiving sedatives and paralytics is troublesome. Hypothermia as well as ischemic injury to liver and kidneys is known to alter the metabolism and delay clearance of these medications. Under these conditions, neurologic function will likely be grossly underestimated, leading to the misleading conclusion of greater neurologic injury and mis-

assignment of prognosis. Because several major professional guidelines have warned against prognostication under these circumstances, this paper raises important concerns. Furthermore, we nd the assignment of poor prognosis even more troublesome because the clinical features used for prognosis were not documented. The importance of timing of neurologic assessment during prognostication is related to the earliest period in which brain structures can recover function to allow reliable clinical testing; prognostication too soon will miss the recovery process and mistakenly assume more permanent neurologic injury. In postcardiac arrest patients who have not been subjected to therapeutic hypothermia, the timing for most reliable assessments starts at 72 hrs after the resuscitation (5, 10, 11). But in those treated with therapeutic hypothermia, the period of observation needs to be at least the same and likely even longer. Therapeutic hypothermia has been demonstrated to improve both survival and quality of life of survivors (35, 10). With our understanding of the impact of therapeutic hypothermia on neurologic recovery and prognostication still evolving, it is imperative that we allow some time for patients to recover. The premature assignment of poor prognosis is worrisome, but even more concerning is the fact that this was undertaken by both medical specialists and neurologists. In this patient population, the assignment of poor prognosis typically results in reduction in the level of care or withdrawal of care leading to death (8). Peberdy et al (6) reported a 66% overall mortality in 14,720 patients who were resuscitated from in-hospital cardiac arrest. Of those who died, 63% were declared do-not-attempt resuscitation after resuscitation, and 43% of those who died had life support withdrawn. It is unclear how the decision of do-not-attempt resuscitation or withdrawal of care was reached, but if we consider the conditions in the Perman study, where premature
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assignment of poor prognosis altered care leading to poor outcomes, the selffullling prophecy is notable. Survival from cardiac arrest will never improve so long as we are giving up on potentially salvageable patients. The impact goes beyond individual survival. How then do we determine efcacy in a clinical trial when mortality may be governed not by disease and treatment, but by withdrawal of care? We are left to infer that premature prognostication and faulty end-of-life decisions have likely biased results of treatment trials toward failure. While this paper provides a springboard for discussion on prognosis, we have to acknowledge its limitations, including: 1) retrospective design, 2) lack of justication for the prognosis assigned from the medical chart, 3) lack of documentation of family and treating team interactions, and 4) the small sample that prevents drawing generalizable conclusions. Despite these limitations, however, it provides us an opportunity to reect on how neurologic assessment is undertaken, how neurologic prognostication can impact mortality at the bedside, and possibly how it can affect the way we undertake clinical trials. We do recognize the need to limit care at some point, especially with worsening morbidity, cost of prolonged futile care, and the moral need to respect patient preferences in light of severe incapacitation. Determining prognosis in critically ill patients remains one of the most important and difcult tasks for physicians in the intensive care unit (13). But it is only when prognostication is undertaken with the most valid, available evidence can we provide the best care that will not only benet our individual patients, but also help move the science forward. It is time that we focus on end-of-life practices to better understand the role that self-fullling prophecy or biological des-

tiny play in patients with poor outcome after resuscitation from cardiac arrest. Romergryko G. Geocadin, MD Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery Johns Hopkins University School of Medicine Baltimore, MD Mary Ann Peberdy, MD Department of Internal Medicine (Cardiology) Virginia Commonwealth University School of Medicine Richmond, VA Ronald M. Lazar, PhD Department of Neurology Columbia University College of Physicians and Surgeons New York, NY

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