title: Understanding Early Decisions to Withdraw Life-Sustaining Therapy in Cardiac Arrest Survivors. A Qualitative Investigation.
abstract: Early withdrawal of life-sustaining therapy contributes to the majority of deaths following out-of-hospital cardiac arrest (OHCA), despite current recommendations for delayed neurological prognostication (≥72 h) after treatment with targeted temperature management. Little is known about clinicians' experiences of early withdrawal of life support decisions in patients with OHCA.
  
  
  
  To explore clinicians' experiences and perceptions of early withdrawal of life support decisions and barriers to guideline-concordant neurological prognostication in comatose survivors of OHCA treated with targeted temperature management.
  
  
  
  We conducted qualitative interviews with intensive care unit (ICU) physicians and nurses following withdrawal of life support in comatose patients with OHCA treated with targeted temperature management. The study was carried out across 18 academic and community hospitals participating in a multicenter, stepped-wedge, cluster-randomized controlled trial designed to improve quality-of-care processes for patients after OHCA in Ontario, Canada. We used a focused thematic analysis to capture barriers to guideline-concordant neurological prognostication and used these barriers to identify potentially modifiable issues.
  
  
  
  The core thematic finding was a high emotional burden of ICU family-team communication in which strong feelings inhibited information transfer and delayed decision making following OHCA. Four subthemes describing sources of communication strain were identified: (1) requests from family members to provide early outcome predictions, (2) incomplete family comprehension of critical care, (3) family requests for early withdrawal of life support based on their understanding of patients' preferences and values, and (4) family-team communication gaps related to prognostic uncertainty. Participants worried that gaps in timely and clear prognostic information contributed to surrogates' perceptions of a poor outcome and to inappropriately early decisions to withdraw life support.
  
  
  
  Family-team communication difficulties may be an underestimated factor leading to early withdrawal of life support in ICUs for individuals who initially survive OHCA.
authors.affiliation: 1 Lawrence S. Bloomberg Faculty of Nursing.|2 Trauma, Emergency and Critical Care Program and.
authors.forename: Craig M
authors.identifier: 0000-0002-5042-0332
authors.initials: CM
authors.lastname: Dale
authors.affiliation: 4 Interdepartmental Division of Critical Care, Department of Medicine.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Tasnim
authors.initials: T
authors.lastname: Sinuff
authors.affiliation: 6 Division of Emergency Medicine, Department of Medicine, and.|5 Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Morrison
authors.affiliation: 4 Interdepartmental Division of Critical Care, Department of Medicine.|8 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|7 Department of Medicine, University Health Network, Toronto, Ontario, Canada; and.
authors.forename: Eyal
authors.initials: E
authors.lastname: Golan
authors.affiliation: 4 Interdepartmental Division of Critical Care, Department of Medicine.|8 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|9 Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
mesh_terms: D001291:Attitude of Health Personnel; D003128:Coma / Q000628:therapy*; D003142:Communication; D032882:Comprehension; D003657:Decision Making; D005190:Family / Q000523:psychology*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007036:Hypothermia, Induced; D007362:Intensive Care Units; D007407:Interviews as Topic; D008297:Male; D009864:Ontario; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications*; D011368:Professional-Family Relations; D011379:Prognosis; D036301:Qualitative Research; D028761:Withholding Treatment
keywords: comatose patient; induced hypothermia; out-of-hospital cardiac arrest; prognostication; qualitative research