Practice Patterns and Ethical Considerations in the Management of Venovenous Extracorporeal Membrane Oxygenation Patients: An International Survey*

Abstract

Objectives: To characterize physicians’ practices and attitudes toward the initiation, limitation, and withdrawal of venovenous extracorporeal membrane oxygenation for severe respiratory failure and evaluate factors associated with these attitudes. Design: Electronic, cross-sectional, scenario-based survey. Setting: Extracorporeal membrane oxygenation centers affiliated with the Extracorporeal Life Support Organization and the International Extracorporeal Membrane Oxygenation Network. Subjects: Attending-level physicians with experience managing adult patients receiving venovenous extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: Five-hundred thirty-nine physicians in 39 countries across six continents completed the survey. Factors that influenced the decision to limit extracorporeal membrane oxygenation initiation included older patient age (46.9%), additional organ failures (37.7%), and prolonged mechanical ventilation (35.1%). Patient comorbidities (70.5%), patient’s wishes (56.0%), and etiology of respiratory failure (37.7%) were factors that influenced the decision to withdraw extracorporeal membrane oxygenation. In multivariable analysis, factors associated with increased odds of withdrawing life-sustaining therapies included pulmonary fibrosis, stroke, surrogate’s desire to withdraw, lack of knowledge regarding patient’s or surrogate’s wishes in the setting of fibrosis, not initiating extracorporeal membrane oxygenation in the baseline scenario, and respondent religiosity. Factors associated with decreased odds of withdrawal included practicing in an environment where it is not legally possible to make decisions against patient or surrogate wishes. Most respondents (90.5%) involved other physicians in treatment decisions for extracorporeal membrane oxygenation patients, whereas only 53.2%, 45.3%, and 29.5% of respondents involved surrogates, awake patients, or bedside nurses, respectively. Conclusions: Patient and physician-level factors were associated with decision-making regarding extracorporeal membrane oxygenation initiation and withdrawal, including patient prognosis and knowledge of patient or surrogate wishes. Respondents reported low rates of engaging in shared decision-making when managing patients receiving extracorporeal membrane oxygenation.

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

“…Ethical challenges [53][54][55] will affect decision making when offering ECMO therapy in an outbreak. There might be uncertainties regarding the potential benefit and duration of ECMO in this context, which might be dynamic as the outbreak evolves and would require regular review.…”

Extracorporeal life support for adults with acute respiratory distress syndrome

“…In these circumstances, criteria regarding continuation or withdrawal of ECMO are not strictly established and may differ among caregivers, ECMO centers, and countries. In a recent survey of 539 physicians from 39 countries across 6 continents, these decisions were strongly influenced by whether a patient’s or surrogate’s wishes were known, the level of consciousness of the patient, and perceived “futility” of the clinical situation [ 75 ]. Weighing the potential benefits and risks of ECMO using predictive survival models [ 39 , 40 ], and improving doctor-patient/surrogate communication surrounding the benefits and limitations of ECMO before its initiation are crucial.…”

“…Weighing the potential benefits and risks of ECMO using predictive survival models [ 39 , 40 ], and improving doctor-patient/surrogate communication surrounding the benefits and limitations of ECMO before its initiation are crucial. Shared decision-making with patients and family regarding end-of-life decisions on ECMO are recommended [ 75 ].…”

COVID-19 Pulmonary Failure and Extracorporeal Membrane Oxygenation: First Experience from Three European Extracorporeal Membrane Oxygenation Centers

“…Depending on the individual patient pathophysiology, vascular status, cardiac function, local expertise, and local resources, the optimal ECMO strategy needs to be considered. [11][12][13] Mortality in critically ill COVID-19 patients ranges between 24 and 68%. 14,15 The clinical course and outcome of COVID-19 patients were influenced by age, gender, body mass index, and coexisting pathology.…”