Challenging ageism in eCPR: the quiet discrimination

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

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Authors and Affiliations

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

   Sasa Rajsic & Robert Breitkopf

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1. Sasa RajsicView author publications

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2. Robert BreitkopfView author publications

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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.

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Correspondence to Sasa Rajsic.

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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

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• Received: 08 September 2025

• Accepted: 09 October 2025

• Published: 17 October 2025

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

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