Khaled was turned down for ECMO support for multiple reasons. Outcomes of unwitnessed out-of-hospital cardiac arrest patients are generally very poor, particularly with prolonged resuscitation. In addition, arrest from hypoxemia due to sick lungs is particularly bad because the CPR is often less effective due to poor gas exchange. He has had a prolonged and severe metabolic acidosis withe at least 2 pH measurements of <6.8, and is requiring four vasopressors, despite normal LV contractility, consistent with autonomic dysfunction and irreversible shock. His likelihood of recovery, even with VA ECMO support is extremely low if not zero. After being turned down for ECMO, he was maintained on the same support overnight, off sedation, with no evidence of neurological function. A CT demonstrated diffuse hypoxic injury and care was withdrawn.