Transient Resumption of Cardiac Activity After Life-Sustaining Measure Withdrawal

Transient resumption of at least 1 cycle of cardiac activity after pulselessness was observed in 14% of patients after withdrawal of life-sustaining measures, according to a study published in the New England Journal of Medicine.

This is a prospective, observational study conducted in 20 intensive care units in 3 countries to determine the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures. After determination of death, the patients were intended to be monitored for 30 minutes.

Resumption of cardiac activity was prospectively assessed by clinicians at the bedside. These observations were retrospectively confirmed by reviewing recorded continuous blood pressure and electrocardiographic (ECG) waveforms. Reviews also allowed to determine the occurrence of additional instances of resumption of cardiac activity.

Of 631 patients (mean age, 63±16 years; 38% women) included, 5 patients (1%) had a clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis.

Retrospective analysis of ECG and blood pressure waveforms from 480 patients (mean age, 65±15 years; 38% women) led to the identification of 67 instances (14%) of resumption of cardiac activity after a period of pulselessness, including the 5 cases reported by clinicians at the bedside. The longest duration between resumption of cardiac activity and pulselessness was 4 minutes 20 seconds. In 19% of patients, the last QRS complex coincided with the last arterial pulse.

“No patients who had a resumption of cardiac activity regained consciousness or survived,” noted the study authors. “However, transient resumption of cardiac activity did occur, which suggests that the physiologic processes of somatic death after removal of life-sustaining measures occasionally include periods of cessation and resumption of cardiac electrical and pulsatile arterial activity.”

Study limitations include the fact that, among 13 clinically reported resumptions of circulation, 2 did not have waveform data available for confirmation of cardiac activity and thus were not included in the estimates. Also, the generalizability of the results may be limited, as patients without arterial pressure catheters were excluded, and 24% of enrolled patients could not be included in the retrospective waveform analysis due to incomplete data.

“Our analysis of clinical reports by bedside clinicians and vital-sign waveform recordings from a large international sample supports the current 5-minute observation period required by most protocols and guidelines for proceeding with organ donation after circulatory determination of death,” concluded the study authors. “Our results also confirm the known phenomenon of electrical cardiac activity continuing in the absence of pulsatile cardiac activity.”

Disclosures: Two authors reported an affiliation with a clinical software company. Please see the original reference for a full list of disclosures.


Dhanani S, Hornby L, van Beinum A, et al. Resumption of cardiac activity after withdrawal of life-sustaining measures. N Engl J Med. 2021;384(4):345-352.