The journey after restart: understanding the multidimensional experience of cardiac arrest survivors

INTRODUCTION Survivorship, in the context of cardiac arrest, refers to the phase following successful resuscitation—either immediately post-return of spontaneous circulation or, more commonly in clinical practice, from the point of hospital discharge. It encompasses the recovery journey across physical, cognitive, psychological and social domains. In Singapore, survival after out-of-hospital cardiac arrest (OHCA) has improved from 11.6% in 2011 to 23.1% in 2016, reflecting the impact of coordinated system-level strategies.1 These gains reflect deliberate investments in strengthening the chain of survival, including the MyResponder application that crowdsources volunteers, and the wide availability of automated external defibrillators. However, most measures of success remain focused on short-term outcomes such as return of spontaneous circulation or hospital discharge survival. In 2020, the American Heart Association (AHA) emphasised survivorship by adding ‘healing and recovery’ as the sixth link in the chain of survival, underscoring the importance of quality of life and reintegration beyond discharge.2 The European Resuscitation Council has echoed similar calls.3 These changes highlight that survival is not the endpoint; rather, it is the beginning of a new phase that continues as survivors and families transition back into their homes and communities. WHY SURVIVORSHIP MATTERS? The lived experience of survivors is multifaceted. Persistent sequelae include fatigue, deconditioning, cognitive impairment, anxiety, depression and post-traumatic stress disorder, with prevalence estimates often exceeding 25% in both survivors and caregivers.4 Family members, or ‘co-survivors’, similarly face significant psychological and caregiving burdens.5 A systematic review of 70 studies suggested that overall health-related quality of life (HRQoL) among survivors may be comparable to that of the general population, but important limitations exist.6 Studies used heterogeneous measures (EuroQol 5 Dimensions, Short Form-36 Health Survey, Cerebral Performance Category, modified Rankin Scale), often with short follow-up. Patients with severe neurological disability were under-represented, and many reports relied only on survivors who were well enough to attend follow-up. These methodological issues limit confidence and may underestimate the true burden of survivorship. More recent meta-analyses echo these findings, noting variability in definitions, outcome tools and follow-up timeframes.7 Beyond clinical outcomes, socioeconomic consequences are significant but under-reported. Many survivors face difficulties returning to employment, with some experiencing reduced productivity, stigma or forced retirement. Caregivers often scale back paid work, intensifying financial strain.8 In Singapore and other Asian settings, cultural stigma surrounding cognitive decline and mental health may further limit help-seeking, compounding unmet needs. While this cultural dimension has not been specifically studied in the context of OHCA survivorship, outcome disparities affecting Asian populations have been observed. For example, a recent United States registry study reported that Asian individuals had significantly lower survival to discharge and favourable neurological outcomes compared to White individuals, despite similar rates of bystander cardiopulmonary resuscitation (CPR).9 Together, these factors emphasise why survivorship research and care must go beyond survival metrics to truly capture patient- and family-centred outcomes. LEARNING FROM INTERNATIONAL MODELS Several health systems have pioneered survivorship frameworks. In the United States, designated cardiac arrest centres integrate cardiology, neurology, psychology and rehabilitation services, often collocated with catheterisation laboratories. These centres emphasise early specialist input and multidisciplinary rehabilitation to improve reintegration.10 In the United Kingdom, the Care After Resuscitation programme delivers pre-discharge education, peer support, 48-hour post-discharge calls and follow-up clinics with screening for quality of life and mental health.11 Evaluations have reported high patient satisfaction and smoother care transitions. In the Netherlands, the ‘Stand Still… and Move On’ nurse-led service identifies cognitive and emotional needs early, enabling timely intervention.12 Despite differences in context, these programmes share three features: multidisciplinary coordination, proactive identification of post-arrest needs and structured, longitudinal follow-up. SINGAPORE’S PROGRESS AND GAPS Singapore’s National Post Cardiac Arrest and Survivorship Workgroup unites cardiologists, emergency physicians, intensivists and neurologists to shape consensus and advance research.13 Its efforts include producing position statements on post-resuscitation care and supporting enhancements to registry data collection. Complementing this, the Singapore Heart Foundation’s Cardiac Arrest Survivors’ Club provides ground-up, peer-led support and caregiver engagement, with increasing participation.14 Local registry data reveal sustained long-term survival, with a median survivor age of 56 years and many surviving beyond a decade. However, disparities persist: men report better HRQoL than women, raising questions about equity and the need for tailored rehabilitation strategies.15 Several plausible mechanisms may underlie this disparity. First, women with OHCA in multi-ethnic Asian Pan Asian Resuscitation Outcomes Study (PAROS) cohorts and international meta-analyses are typically older, have more comorbidities, arrest more often at home and present less frequently with shockable rhythms—all factors associated with poorer functional recovery and quality of life.16,17 Second, sex differences along the care pathway may accumulate: women are consistently less likely to receive bystander CPR or early defibrillation in both Asian and Western settings, and often have lower use of invasive post-arrest therapies and cardiac rehabilitation.18,19 Cardiac rehabilitation participation, in turn, is associated with improved HRQoL and reduced anxiety and depression in Asian and Singaporean cohorts.20 Third, women after OHCA and other cardiac events report higher psychological distress and worse HRQoL than men, and in Asian contexts, they may face heavier caregiving roles and greater stigma around mental health help-seeking.21,22 Taken together, these hypotheses suggest that sex differences in HRQoL may reflect cumulative structural and social disadvantage rather than individual ‘resilience’ alone, and should be explicitly examined in upcoming Singaporean cohorts. Despite these initiatives, post-arrest services remain fragmented and dependent on individual clinicians rather than embedded pathways. For example, some hospitals have integrated physiotherapy and occupational therapy into routine follow-up, while others do not. Cognitive, psychological and functional assessments are inconsistently applied, and access to rehabilitation varies across institutions. These inconsistencies indicate that Singapore already has many of the building blocks of survivorship care, but they are not yet organised within a shared conceptual and operational framework. To move from clinician-dependent, ad hoc services to reliable and system-level provision, a common language for the domains and trajectories of survivorship is needed. A MULTIDIMENSIONAL FRAMEWORK FOR SURVIVORSHIP Against this backdrop, international frameworks offer a useful starting point. The AHA survivorship statement proposes nine domains: cardiopulmonary, neurological, cognitive/communication, affective, social, general medical, functional, participation and quality of life.23 Adopting this framework in Singapore would support systematic screening pre-discharge, integration of neurocognitive and psychosocial services into cardiac rehabilitation, scheduled follow-up at 3, 6 and 12 months, and explicit inclusion of caregiver needs in care planning. For example, cardiopulmonary follow-up could include optimisation of heart failure therapy and implantable cardioverter-defibrillator monitoring. Neurological recovery could be tracked through neuropsychological testing, akin to stroke rehabilitation models. Psychosocial health could be assessed using validated screening tools such as the Hospital Anxiety and Depression Scale, while social reintegration could focus on return-to-work programmes and caregiver education. The ‘participation’ domain has particular resonance in Singapore, where survivors are relatively young and vocational reintegration is crucial. The ‘general medical’ domain is also highly relevant, given the burden of comorbid diabetes mellitus and hypertension, which complicate recovery. Table 1 provides a structured summary of these nine domains, with examples of needs and context-specific recommendations for Singapore. Implementing such a framework would embed survivorship into the continuum of cardiac arrest care, bridging the current gap between hospital discharge and long-term recovery.Table 1: Survivorship domains and recommended actions for Singapore.THE ROAD AHEAD Singapore’s improvements in OHCA survival demonstrate the power of coordinated investment. A similar commitment to survivorship is needed to ensure survivors thrive after discharge. We look forward to results from an ongoing National Medical Research Council-funded prospective population-based cohort study, the Quality Survivorship after Cardiac Arrest (QualiCAS), which follows up on OHCA survivors and their caregivers, with the primary aim of determining neurological function, HRQoL and physical, psychological, cognitive and social outcomes.24 This effort is crucial in generating evidence to inform national policy and guide resource allocation. Beyond research, several priorities emerge. First, survivorship pathways should be formalised within care bundles, ensuring that discharge planning includes rehabilitation, psychological screening and caregiver engagement. Second, survivorship care should be integrated with primary and community care, consistent with Healthier SG reforms, to ensure continuity beyond specialist settings. Third, outcome measures in registries must be expanded to include validated functional and psychosocial metrics, enabling benchmarking across Asia. Fourth, disparities such as gender differences in HRQoL should be addressed through targeted initiatives, potentially including tailored rehabilitation programmes for women. Finally, peer support networks such as the Survivors’ Club should be strengthened and formally linked to hospital services, recognising their low-cost, high-impact role in recovery. The outputs of QualiCAS will be invaluable for informing these initiatives and aligning survivorship priorities with broader health policy. Reframing survivorship as a key endpoint will ensure that success is measured not only in lives saved, but in lives meaningfully lived. CONCLUSION Sudden cardiac arrest survivors face complex challenges in recovery and rehabilitation. A system that integrates rehabilitation, neurocognitive care, psychosocial support and peer engagement is essential. Singapore has proven it can double OHCA survival; the next step is to ensure survivors thrive, not merely survive. By embedding survivorship into national strategy and aligning with broader reforms such as Healthier SG, Singapore can extend its resuscitation success to include lives worth living. Financial support and sponsorship Nil. Conflicts of interest Ho AFW is a member of the SMJ Editorial Board and was thus not involved in the peer review and publication decisions of this article.