How Should ECMO Initiation and Withdrawal Decisions Be Shared?

Abstract

Extracorporeal membrane oxygenation (ECMO) is a new technology used to rescue patients with severe circulatory or respiratory failure and help bridge them to recovery or to definitive therapies like device implantation or organ transplantation. The increasing availability and success of ECMO has generated numerous ethical questions about its use and potential misuse. This commentary on a case of a patient who is no longer a candidate for transplant but wishes to continue ECMO identifies strategies clinicians can use to reconcile competing responsibilities. Case JL is a 20-year-old man with progressive interstitial lung disease that developed after burning brush treated with fertilizer and weed spray. Four months after his initial diagnosis, he was referred to Dr M, a lung transplantation specialist. In the ensuing year, JL's lung disease progressed, and Dr M recommended listing him for transplantation. Unfortunately, one week after being listed for transplant, JL developed parainfluenza pneumonia and was admitted to a medical intensive care unit. His condition rapidly deteriorated and he required intubation for mechanical ventilatory support. Dr M and the cardiothoracic surgery team recommended initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to lung transplantation. They discussed the risks and benefits of ECMO with JL and his family and indicated that the goals of ECMO in JL's case were to liberate him from mechanical ventilatory support and allow him to participate in physical therapy while awaiting a transplant. They disclosed that he would only remain listed for transplant if his other organs remained healthy, he remained free of serious complications, and he could get out of bed and walk every day. JL and his family consented to the procedure, and over the next several days he was successfully cannulated for VV-ECMO, weaned from mechanical ventilatory support, ambulated daily in the intensive care unit (ICU), and relisted for lung transplantation. Four days later, JL developed a black skin lesion on the nose, groin, and axilla. A biopsy showed invasive mucormycosis-a rare and difficult to treat fungal infection. This new diagnosis disqualified JL for transplantation.

Ethics in extracorporeal life support: a narrative review

“…Early works by Bartlett [ 3 ] and Lantos et al [ 10 ] describe how ECLS research is linked to its ethical prerequisites and consequences; Jaramillo et al [ 17 ] point out the rationality of deliberation in limiting ECLS; Carlisle et al [ 65 ] oppose the clear-cut understanding of futility; and in the face of the common utilitarian ECLS-prioritisation model advocated by Abrams et al [ 66 ], Supady et al [ 26 ] prefer the egalitarian approach of Norman Daniels, which is based on the right to participate in a fair and transparent allocation process. Finally, Ross [ 67 ] and Halpern et al [ 55 ] depict the notion of death as pragmatic and therefore alterable.…”

“…While several historical cost-effectiveness analyses have shown it to be cost-efficient for some patient populations and indications in certain national health systems, at least compared to other highly cost-intensive interventions, this is not universally the case [ 1 ]. Initiating or continuing ECLS indiscriminately conflicts at a minimum with physicians’ duty to allocate resources responsibly [ 17 , 18 ]. However, the lack of clear evidence limits the use of prospective economic calculations.…”

“…As the objective of ECLS is to help patients survive until recovery or restitution, initiating or continuing ECLS is generally considered inappropriate if there are no such prospects [ 39 ]. This applies both to pre-ECLS patients and to those already undergoing it, as most authors suggest that withholding and withdrawing ECLS are ethically equivalent [ 17 , 38 , 40 , 41 ]. However, some highlight the cruelty of withdrawing ECLS from objecting patients [ 17 , 18 ].…”

“…This applies both to pre-ECLS patients and to those already undergoing it, as most authors suggest that withholding and withdrawing ECLS are ethically equivalent [ 17 , 38 , 40 , 41 ]. However, some highlight the cruelty of withdrawing ECLS from objecting patients [ 17 , 18 ]. For patients trapped on this metaphorical bridge to nowhere, a no-escalation-strategy might provide a way out [ 42 ].…”

Ethical and Legal Concerns Associated With Withdrawing Mechanical Circulatory Support: A U.S. Perspective

“…Processes for withdrawing specific MCS technologies-VAD, TAH, and ECMO support-are described elsewhere (33)(34)(35)(36)(37). Overall, withdrawal of MCS should be based on established palliative care principles and evidence-based best practices.…”