The authors reply.

We would like start by emphasizing that our recently published article (1) in Critical Care Medicine does not suggest that cardiopulmonary resuscitation is futile in hospitalized coronavirus disease 2019 (COVID-19) patients suffering from cardiac arrest. We sought to use our experience to generate robust debate and encourage further research into a very important question that has a large impact on resource allocation.

Nowhere in our article did we suggest early termination of resuscitative efforts and premature withdrawal of life-sustaining measures. We agree that every effort must be made to guard against therapeutic nihilism in any clinical endeavor. At the time of submission of our article, there was no data in the United States about the survival to discharge in COVID-19 patients suffering in-hospital cardiac arrest, and our study added to the rapidly evolving body of evidence at a time when little was known about COVID-19.

Since the publication of our article, there have been more recent data, including the authors’ article (3) showing that cardiopulmonary resuscitation in COVID-19 patients with in-hospital cardiac arrest is certainly not futile. We believe that single-center studies such as ours helped spur more studies that have driven best practices for the care of COVID-19 patients.

We agree with Mitchell and Abella (2) that the variations observed between hospitals in outcomes of cardiac arrest in COVID-19 patients result from a complex interplay of factors ranging from care variations to resource availability, patient selection, and patient demographics. In our institution, the survival to discharge among in-hospital cardiac arrest patients in the prior year (pre-COVID) was 34.7% (1). We have previously described the demographics of our hospitalized COVID-19 patients, who are sicker with higher comorbidity burden compared with other areas (4). The 11.9% survival to discharge from Mitchell et al (3) should be compared with our data with great deal of caution. Our patient demographics were vastly different compared with theirs. More than 90% of our patients were African-Americans, and it is well known that African-Americans have significantly lower survival rates after cardiac arrest compared with Caucasian patients (5). Compared with their patient cohort, our patients had significantly higher prevalence of hypertension, diabetes, and chronic kidney disease (1, 3). The prevalence of obesity and morbid obesity in our cohort was quite high as well. The likelihood of success from cardiopulmonary resuscitation depends on the cause of arrest as well as on the health status of the patient (6). A number of pre-arrest and intra-arrest factors associated with poor survival after in-hospital cardiac arrest were present in our patients.

We agree that goals of care conversations should be a core component of the care pathway for every critically ill patient at every stage of their care in the hospital. Finally, we would like to reiterate that the title and conclusions of our article were meant to highlight the need for more data about in-hospital cardiac arrest in COVID-19 patients and not to label cardiopulmonary resuscitation futile in COVID-19.