Dear Editor,
We read with great interest the case report by Nagamura et al., describing the unexpected survival of a 90-year-old woman after prolonged hypothermic cardiac arrest treated with extracorporeal cardiopulmonary resuscitation (ECPR) and subsequent neurosurgical intervention for a subdural hematoma [1]. We particularly appreciate the authors’ concluding remark that, in addition to clinical status and healthcare resources, a patient’s individual values must be considered when initiating ECPR. However, the report itself contains no documentation of the patient’s values, preferences, or goals of care, and includes no patient-reported outcome measures (PROMs). This absence raises substantial ethical concerns that warrant critical discussion.
Generally, medical decision-making should rest on three pillars: i) medical indication based on evidence, ii) patient values and preferences, and iii) justice, including distributive justice [2].
Against this background, the decision to initiate ECPR in a nonagenarian with prolonged cardiac arrest, pre-existing dementia, and subsequently identified traumatic brain injury raises questions regarding proportionality. Although the HOPE score estimated a 76% survival probability, the authors acknowledge that it does not account for frailty, multimorbidity, or the high likelihood of severe complications in very elderly patients [3]. Reliance on a prognostic tool that excludes these essential parameters risks promoting interventions that may be physiologically possible yet ethically questionable. Recent reviews show that ECPR programs worldwide vary substantially in age criteria, with upper limits ranging from 50 to 80 years and a threshold of 75 years most commonly applied [4].
The patient's clinical course further underscores these concerns. She underwent a > 2-month hospital stay marked by cardiac tamponade requiring drainage and massive transfusion, subdural hematoma, and neurosurgical intervention, ultimately being discharged with significant disability (CPC 3) before improving to a wheelchair-dependent CPC 2 in a long-term care facility. This trajectory illustrates the enormous resource utilization associated with such interventions. In an era of increasing demographic aging and persistent ICU capacity constraint, the justification for extremely resource-intensive therapies in patients of very advanced age must be carefully scrutinized.
Equally concerning is the implicit assumption that neurological survival constitutes sufficient justification for escalating care. Although the patient ultimately lived until age 94, she spent the remainder of her life in institutional care with markedly limited mobility. The case report provides no information regarding PROMs, patient values, or goals of care, all of which are central to ethically grounded decision-making in geriatric critical care. The absence of any description of shared decision-making, either before or after initial recovery, makes it unclear whether less invasive or palliative approaches were considered.
Finally, the report touches only briefly on the moral implications of allocating extensive resources to a case where the likelihood of restoring meaningful independence was inherently limited. Respect for human dignity requires not only providing life-sustaining support when indicated, but also recognizing when such treatment may be disproportionate or inconsistent with a patient’s best interest.
Taken together, we are concerned that the reported outcome may be interpreted as endorsement of aggressive treatment strategies in very elderly patients. Exceptional survivors should not be used to normalize extraordinary interventions in populations for whom the burden of treatment most often outweighs potential benefit. Publishing such rare success stories without adequate ethical contextualization risks promoting therapeutic overreach.
In conclusion, while this case demonstrates what is technically feasible, it also highlights the urgent need for clear ethical frameworks to guide decision-making in extreme-age patients undergoing highly invasive interventions such as ECPR. We encourage future case reports to more directly address these aspects, including frailty assessment, resource stewardship, patient autonomy, ethical considerations, and PROMs beyond mere survival.
Acknowledgements
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Authors’ contributions
HS drafted the manuscript, and all authors contributed substantially to its revision. HS takes responsibility for the paper as a whole.
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Competing interests
The authors declare no competing interests.
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References
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