Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda

Abstract

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital*

“…Expanding extracorporeal membrane oxygenation (ECMO) use in recent years has increased decision-making challenges for the clinical team (1–4). This invasive life-sustaining therapy supports patients through critical illness but is only provided as a temporary measure (5).…”

Extracorporeal Membrane Oxygenation Ethics: What Is Your Question?*

“…Amid widespread recognition in critical care of a need to address the ethical dilemmas associated with extracorporeal membrane oxygenation (ECMO) (1), there is a paucity of work that demonstrates what exactly is needed and helpful regarding ethics consultation for pediatric patients receiving ECMO. While some suggest an automatic ethics consult with every ECMO course (2, 3), this seems an inefficient use of resources of the generally small pediatric clinical bioethics consult team in most pediatric centers.…”

“…While this can be an important component of enhancing ethical facility in teams, which can decrease moral distress (10), this may represent a different mechanism of supporting teams on ECMO. Educational aspects of understanding ethical justifications surrounding the noted themes of discontinuing ECMO, and ECMO candidacy may reduce distress and lessen the need for a patient specific ethics consult and may be important and helpful aspects of education for ECMO and intensive care teams (1). Such work might also be supported with the development of frameworks and robust decisional processes surrounding ECMO.…”

“…Better understanding of the intersection of end of life and ethical considerations may enhance focused palliative care consultation earlier in an unsuccessful ECMO course. In conjunction, benefits to the family/patient cannot be ascertained from this examination but should be studied (1). Of note, no ethics consults were generated by families in this series, and this may offer additional impetus to both study the family experience and for ethics consult services to reflect on their availability and the patient and family knowledge of their services.…”