Clarification and Mitigation of Ethical Problems Surrounding Withdrawal of Extracorporeal Membrane Oxygenation

Abstract

Extracorporeal membrane oxygenation (ECMO) is temporary life-support technology that provides time to rest the cardiac and respiratory system of critically ill people with acute, reversible medical conditions. Health care providers face emotional and challenging situations, where death may result, when withdrawing ECMO. A deepening of understanding of the ethical issues involved can aid clinicians in handling such difficult situations, leading to a possible mitigation of the moral problems. Toward this end, the ethical issues raised in the consideration of ECMO withdrawal are analyzed with respect to the ethical principles and concepts of autonomy, nonmaleficence/beneficence, medical futility, moral distress, and justice. In particular, these issues are considered in relation to how they affect and can be addressed by staff nurses and advanced practice nurses in the intensive care unit. Advanced practice nurses in particular can represent the voice of nurses to promote a healthier workplace in situations of moral distress related to stopping ECMO life-support technology and in developing clear and consistent guidelines for ceasing ECMO treatment, all leading toward clarification and mitigation of the ethical problems surrounding the withdrawal of this critical technology.

Key Factors in Decision Making for ECLS: A Binational Factorial Survey

“…Such decisions may also occur in cases in which relatives wish for the treatment to continue even though it is futile 40 or can be attributed to moral distress among health care professionals. 41 The study suggested a small but significant negative effect of noncovered treatment costs for ECLS. In the light of rising health care costs, particularly in end-of-life care, this finding is not surprising.…”

“…Such decisions may also occur in cases in which relatives wish for the treatment to continue even though it is futile 40 or can be attributed to moral distress among health care professionals. 41 …”

Principlism and Personalism. Comparing Two Ethical Models Applied Clinically in Neonates Undergoing Extracorporeal Membrane Oxygenation Support

“…In this instance they can bring into question the decisional authority of the family. If both parties have moral grounding for their judgment of best interest, however, the determination becomes even more complicated (4–6, 22, 23).…”

“…This aspect introduces the considerations of futility. Futility considerations have long been argued in the medical literature, but remain ill defined (23, 27–29, 37, 38). In the recent era, futility is most often considered when the goals of a medical intervention cannot be or are not achieved (physiologic futility) (37, 38).…”

The Role of Palliative Care Consultation in Withdrawal of Life-Sustaining Treatment among ICU Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): A Retrospective Case-Control Study

“…1,[4][5][6] However, in critically ill patients with poor prognosis, extending the duration of receiving life supporting measures via treatment with EMCO, might not seem a very cost-effective way of utilizing the healthcare system resources 7 and has been even ethically debated. 8,9 A medically unjustifiable continuation of care in these cases, also referred to as "a bridge to nowhere", is burdensome, costly to the healthcare system and emotionally overwhelming to the patients' next of kin. Nevertheless, withdrawal of life-sustaining treatments (WOLST) such as that with VV-ECMO is not a straightforward decision to attain, not by the healthcare providers or by the patient's advance directives.…”