Response to “Letter to Early do-not-attempt resuscitation orders and neurological outcomes in older out-of-hospital cardiac arrest patient”

Abstract

We thank Dr. Tangkamolsuk and colleagues for their insightful comments and interest in our recent article, “Early do-not-attempt resuscitation orders and neurological outcomes in older out-of-hospital cardiac arrest patient: A multicenter observational study.”^{1, 2} We appreciate the opportunity to clarify several important points raised.

First, Tangkamolsuk et al.¹ highlighted the absence of a comprehensive assessment of patient symptoms or pain management associated with Do Not Attempt Resuscitation (DNAR) decision-making. We acknowledge this limitation. However, it is crucial to emphasize that our study exclusively included patients who had achieved the return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA), meaning our entire cohort presented with comatose post-cardiac arrest syndrome. Nearly all these patients were unconscious, mechanically ventilated, and incapable of personally communicating their preferences regarding DNAR orders. In the field of emergency and critical care, it has been reported that DNAR orders are often decided not by the patients themselves but by their families or medical professionals.³ Furthermore, patients who already had explicit DNAR orders prior to hospital admission were excluded from the analyses.

In this clinical context, pain and symptom management is routinely and rigorously provided using sedation and analgesia protocols as part of standardized intensive care practices. Given these standard protocols and patient conditions, we believe variability in pain management or subjective symptom assessment is unlikely to have significantly influenced DNAR decision-making in our cohort. Nevertheless, as the authors appropriately suggest, prospective studies specifically exploring these dimensions in DNAR decisions would be valuable.

Second, we appreciate the authors' comment regarding the potential effects of institutional policies and clinicians' personal judgments or biases. To minimize such confounding, our analysis employed propensity score analysis with inverse probability of treatment weighting (IPTW) and generalized estimation equation modeling to account for clustering by institution. Despite these statistical adjustments, we agree that institutional and personal variations cannot be fully excluded as influencing factors.

Finally, the authors raised an important point regarding religious and socioeconomic influences. Previous research has indicated a limited correlation between these factors and DNAR decisions, especially within the Japanese healthcare and sociocultural environment.^{4, 5} Japan's national health insurance provides comprehensive coverage, significantly reducing financial barriers to healthcare. Moreover, the cultural context in Japan, where individuals commonly practice multiple religions without adherence to a single doctrine, makes it less likely that religious beliefs significantly impact DNAR decisions. Nevertheless, we concur that future research should consider these factors in different settings.

We sincerely thank the authors for emphasizing these relevant perspectives. We hope our findings stimulate further research and discussion on DNAR orders in acute care settings.

The authors declare no conflicts of interest.

Approval of the research protocol: N/A.

Informed consent: N/A.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.