Challenging ageism in eCPR: the quiet discrimination

Abstract

To the editor, 

We read with great interest the report on left-digit bias (LDB)^{Footnote 1}and invasive treatments among out-of-hospital cardiac arrest patients with shockable rhythm [1]. This prospective, multicenter observational study included data from approximately 140 hospitals and a total of 5,943 patients across Japan. The authors identified a significant LDB affecting ECMO implementation at age 70, with rates declining from 34.2% to 24.5%. Despite this steep decline, the analysis revealed no significant discontinuities in neurological recovery or one-month survival across age thresholds, challenging the rationale behind rigid age-based treatment cutoffs.

Evidence supporting the efficacy of extracorporeal cardiopulmonary resuscitation (eCPR) continues to expand, and the study by Miyamoto et al. represents an important contribution to this growing body of high-quality data. While definitive inclusion criteria for eCPR must ultimately be guided by future studies, we emphasize the critical importance of avoiding age discrimination.

Placing disproportionate weight on age as a categorical variable, while overlooking clinical dimensions of comorbidities and frailty, risks reducing complex critical care decisions to crude arithmetic. Although this approach simplifies patient selection, it fails to capture the heterogeneity of aging and the wide variability in physiological resilience among older adults. Consequently, rigid adherence to these cutoffs risks excluding patients who, despite their chronological age, may possess sufficient physiological reserve and rehabilitation potential to benefit from advanced therapies.

Negative societal and clinical perceptions of aging often shape treatment decisions. Older adults may be denied indicated therapies due to assumptions about reduced adaptability, diminished benefit, or the false belief that their conditions are merely the natural consequence of aging [2]. Such attitudes foster systematic undertreatment and are reflected in evidence of covert age-based rationing, especially in cardiac care, palliative medicine, and access to high-risk but potentially life-saving interventions.

These tensions were thrown into stark relief during the COVID-19 pandemic [3]. Triage proposals, rushed into place under the urgency of crisis, drew criticism for undermining the constitutional principle of the equal worth of life and for eroding human dignity [4]. In response, alternative allocation strategies, such as randomized allocation or “first-come, first-served” principles were proposed to safeguard fairness and mitigate discriminatory practices.

Against this backdrop, two ethical frameworks contend for primacy. Utilitarian approaches seek to maximize benefit, often by prioritizing patients expected to gain the greatest number of “life-years”. Yet this arithmetic, efficient as it may seem, risks quiet age discrimination and conflicts with the principle of non-discrimination itself [5]. In contrast, deontological ethics grounds decision-making not in sums but in duties, rights, and inviolable moral principles. It affirms the equal respect owed to every individual, ensuring that the elderly retain a fair and meaningful chance of survival. Under this egalitarian lens, patients with comparable prognoses deserve equal treatment - even if such fairness comes at the cost of fewer aggregate life-years [5].

Legal considerations reinforce this moral claim. In many jurisdictions, explicit age-based rationing sits uneasily with anti-discrimination laws and human rights frameworks. The real distinction, therefore, is between biological age, which may inform prognosis, and chronological age, which in isolation should never determine access to care.

To complement chronological age, integrating structured assessments of physiological reserve and frailty into ECMO decision-making may be beneficial. Tools such as the Clinical Frailty Scale (CFS) have been shown to predict outcomes and guide management in critically ill older patients, including both medical and trauma populations [6,7,8,9]. While these tools have limitations, including potential LDB when applying thresholds, they provide an evidence-based framework for evaluating patients beyond chronological age. In acute situations, age may still be used as a preliminary consideration; however, implementing a “bridge to decision” approach allows clinicians to gather additional information on frailty, autonomy, comorbidities, and patient or family preferences.

In clinical practice, this means structured and transparent decision-making processes. The advanced age alone may not be considered a contraindication for initiating ECMO support. Optimal patient selection requires a careful appraisal of the circumstances surrounding cardiac arrest and resuscitation, paired with a nuanced evaluation of comorbidities, frailty, and rehabilitation potential. These considerations, taken together, must form the backbone of clinical judgment.

Future research must move beyond rigid age thresholds. An individualized, patient-centered approach should take precedence over sole reliance on chronological age. Recognizing and addressing LDB is essential to promote more precise and evidence-based decision-making in resuscitation, where age frequently influences eligibility for advanced interventions.

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

1. Left-digit bias (LDB) occurs when dispro ortionate weight is given to the leftmost digit of a number during decision-making. In clinical practice, this bias can influence treatment decisions based on arbitrary age thresholds (e.g., 69 vs. 70 years), despite minimal biological differences. Individuals just below an age cutoff are more likely to receive aggressive or guideline-adherent care compared to those just above it.

eCPR:

Extracorporeal cardiopulmonary resuscitation

CPR:

Cardiopulmonary resuscitation

1. Miyamoto Y, Kitamura T, Zha L, Komukai S, Oka S, Shiozumi T, et al. Left-digit bias in outcomes and invasive treatments among out-of-hospital cardiac arrest patients with shockable rhythm: a nationwide multicenter observational study with regression discontinuity design analysis. Crit Care. 2025;29(1):389.

   Article PubMed PubMed Central Google Scholar

2. Loh KP, Soto-Perez-de-Celis E. Addressing ageism with geriatric assessment in clinical practice and research. JCO Oncol Pract. 2024;20(12):1559–62.

   Article PubMed Google Scholar

3. Joebges S, Biller-Andorno N. Ethics guidelines on COVID-19 triage-an emerging international consensus. Crit Care. 2020;24(1):201.

   Article PubMed PubMed Central Google Scholar

4. White DB, Lo B. Mitigating inequities and saving lives with ICU triage during the COVID-19 pandemic. Am J Respir Crit Care Med. 2021;203(3):287–95.

   Article CAS PubMed PubMed Central Google Scholar

5. Vearrier L, Henderson CM. Utilitarian principlism as a framework for crisis healthcare ethics. HEC Forum. 2021;33(1–2):45–60.

   Article PubMed PubMed Central Google Scholar

6. Flaatten H, Guidet B, Andersen FH, Artigas A, Cecconi M, Boumendil A, et al. Reliability of the clinical frailty scale in very elderly ICU patients: a prospective European study. Ann Intensive Care. 2021;11(1):22.

   Article PubMed PubMed Central Google Scholar

7. Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw SM, Leaver SK, Beil M, Du B, Forte DN, Angus DC, et al. The trajectory of very old critically ill patients. Intensive Care Med. 2024;50(2):181–94.

   Article PubMed Google Scholar

8. Legros V, Seube-Remy PA, Floch T, Chauchard C, Leclercq-Rouget M, Prevot-Minella PA, et al. Frailty and 6-month trajectory of elderly trauma patients over the age of 65 years admitted to intensive care unit for severe trauma: experience of a level 1 trauma center. BMC Geriatr. 2024;24(1):759.

   Article PubMed PubMed Central Google Scholar

9. Muscedere J, Bagshaw SM, Kho M, Mehta S, Cook DJ, Boyd JG, et al. Frailty, outcomes, recovery and care steps of critically ill patients (FORECAST): a prospective, multi-centre, cohort study. Intensive Care Med. 2024;50(7):1064–74.

   Article PubMed PubMed Central Google Scholar

Download references

Not applicable.

This research received no external funding.

Authors and Affiliations

1. Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, 6020, Austria

   Sasa Rajsic & Robert Breitkopf

Authors

1. Sasa RajsicView author publications

   Search author on:PubMed Google Scholar

2. Robert BreitkopfView author publications

   Search author on:PubMed Google Scholar

Contributions

Conceptualisation, S.R. and R.B.; Data curation, S.R.; Formal analysis, S.R.; Investigation, S.R.; Methodology, S.R.; Project administration, S.R.; Software, S.R.; Supervision, S.R. and R.B.; Validation, S.R. and R.B.; Visualisation, S.R.; Writing—original draft, R.B. and S.R.; Writing—review and editing, S.R. and R.B. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Sasa Rajsic.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This comment refers to the article available online at https://doi.org/10.1186/s13054-025-05629-8.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

Cite this article

Rajsic, S., Breitkopf, R. Challenging ageism in eCPR: the quiet discrimination. Crit Care 29, 441 (2025). https://doi.org/10.1186/s13054-025-05715-x

Download citation

• Received: 08 September 2025

• Accepted: 09 October 2025

• Published: 17 October 2025

• DOI: https://doi.org/10.1186/s13054-025-05715-x

Share this article

Anyone you share the following link with will be able to read this content:

Get shareable link

Sorry, a shareable link is not currently available for this article.

Copy shareable link to clipboard

Provided by the Springer Nature SharedIt content-sharing initiative