Extra corporeal membrane oxygenation support: ethical dilemmas

Abstract

The vast expansion of patients treated with of extra corporeal membrane oxygenation (ECMO) emerge novel ethical questions about the use of this new technology. In regard the indications, duration of support and timing of withdrawal of support, these questions sometimes create disagreement among surrogates, between health care team and surrogates, and even disagreement among health care team, these disagreements occurs because of the extreme emergency of support initiation, the ambiguity of the outcome as well as lack of clarity on the intended treatment direction, whether it is ineffective, bridge to recovery or bridge to lifetime mechanical support or transplant. In this article we discuss these questions through patients' scenarios.

Can the Principles of Research Ethics Help Us Distribute Clinical Resources More Fairly?

“…ECMO is an advanced, highly expensive medical technology that requires significant levels of coordination across healthcare specialists. Although ECMO is available at many tertiary care hospitals, demand greatly exceeds capacity across the U.S. As a result, decisions about who should be offered this technology have generated much controversy (Kanto and Bunyapen 1998), largely centered on how to distribute this life-preserving technology fairly (Makdisi and Makdisi 2017).…”

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

“…Makdisi and Makdisi [4] explain "It is important not to force the family into making decisions that are against their beliefs and to provide them with adequate psychological support through and after the process, it is also important to understand their emotional needs, and understand the program from their perspective" [1,12]. However, Abrams et al [1] argue, "a strong case can be made to discontinue the intervention, with appropriate concessions of timing to the surrogates.…”

“…Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been widely described as a bridge to recovery for acute reversible illnesses, transplantation, ventricular assist devices (VADs), or when the prognosis of patients with cardiorespiratory failure is uncertain [1][2][3][4]. Advancement of this technology has increased accessibility of ECMO and mobile ECMO teams, leading to several ethical issues of VA-ECMO.…”

Ethical challenges and terminal deactivation of left ventricular assist device

“…Is the new condition acceptable by the patient or not? Is the goal the quantity or the quality of life (8)? What is the psychologic status of the patient?…”

“…This decision of LVAD support should be balanced against non-maleficence of the patient. All these gray area and unanswered questions could create disagreement among surrogates, disagreement among health care providers, and surrogates over stopping or continuing this modality of treatment (8,9). LVAD deactivation might occur in three scenarios: (I) patient with LVAD and in critical condition in intensive care unit, in this condition there is no exit strategy and the treatment is considered futile or no longer meets its intended goals.…”