Extracorporeal Membrane Oxygenation as a Bridge to Chemotherapy in an Orthodox Jewish Patient

Abstract

Objective. Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for cardiopulmonary support offers survival possibilities to patients who otherwise would succumb to cardiac failure. Often referred to as “a bridge to recovery,” involving a ventricular assist device or cardiac transplantation, this technology only affords temporary cardiopulmonary support. Physicians may have concerns about initiating VA‐ECMO in patients who, in the absence of recovery or transfer to longer‐term therapies, might assert religious or cultural objections to the terminal discontinuation of life‐sustaining therapy (LST). We present a novel case of VA‐ECMO use in an Orthodox Jewish woman with potentially curable lymphoma encasing her heart to demonstrate the value of anticipating and preemptively resolving foreseeable disputes. Patient. A 40‐year‐old Hasidic Orthodox Jewish woman with lymphoma encasing her right and left ventricles decompensated from heart failure before chemotherapy induction. The medical team, at an academic medical center in New York City, proposed VA‐ECMO as a means for providing cardiopulmonary support to enable receipt of chemotherapy. Owing to the patient's religious tradition, which customarily prohibits terminal discontinuation of LST, clinical staff asked for an ethics consultation to plan for initiation and discontinuation of VA‐ECMO. Interventions. Meetings were held with the treating clinicians, clinical ethics consultants, family, religious leaders, and cultural liaisons. Through a deliberative process, VA‐ECMO was reconceptualized as a bridge to treatment and not as an LST, a designation assigned to the chemotherapy on this occasion, given the mortal threat posed by the encasing tumor. Conclusion. Traditional religious objections to the terminal discontinuation of LST need not preclude initiation of VA‐ECMO. The potential for disputes should be anticipated and steps taken to preemptively address such conflicts. The reconceptualization of VA‐ECMO as a bridge to treatment, rather than as an LST, can allow patients with objections to the terminal discontinuation of LST to receive interventions, such as chemotherapy, that might otherwise be precluded by critical physiology.

Case Report: Refusal of an Veno-Arterial Extracorporeal Membrane Oxygenation Due to Malignant Disease? — An Extremely Rare Form of Cardiac Involvement in Acute Myeloid Leukemia

“…Due to the known risks and the relative contraindications, the published experience with VA-ECMO in children and adult patients with hematologic malignancies is limited to some single cases and a registry analysis (2)(3)(4)22). One of these cases is about a child who suffered cardiac arrest when first diagnosed with T-lymphoblastic lymphoma that infiltrates the heart.…”

“…It is indicated for potentially reversible, life-threatening forms of cardiac failure as “bridge to recovery,” “bridge to next decision” or “bridge to transplant or assist device” ( 1 ). There is hardly any data on the implantation of VA-ECMO in adult cancer patients ( 2 – 4 ).…”

Should Long-Term Life-Sustaining Care Be Started in Emergency Settings?

“…VA-ECMO does not fix underlying cardiopulmonary pathology; rather, it is a temporizing measure that offers patients time for their heart to recover or-in the absence of recovery-for transition to long-term circulatory support, such as a ventricular assist device (VAD) or cardiac transplantation. 4 In a life-threatening situation, the emergency presumption of consent justifies caring for an incapacitated patient without consent from a surrogate. 5 Treatment is provided based on the assumption that a reasonable patient with decision-making capacity would consent to a life-saving intervention.…”

Finding a Bridge to Somewhere: An Ethical Framework for Veno-Arterial Extracorporeal Membrane Oxygenation Decisions

“…Meltzer and colleagues [13] describe a 40-year-old Hasidic Orthodox Jewish mother of four children, diagnosed with large B-cell lymphoma, which contributes to acute heart failure and the need for ECMO treatment. Prior to treatment, discussions surrounding the potential need to withdraw ECMO were discussed early on with the patient, her family, and their rabbi.…”