Clinician Ethical Perspectives on Extracorporeal Membrane Oxygenation in Practice

Abstract

Purpose: Extracorporeal membrane oxygenation (ECMO) is an expensive and scarce life sustaining treatment provided to certain critically ill patients. Little is known about the informed consent process for ECMO or clinician viewpoints on ethical complexities related to ECMO in practice.

Methods: We sent a cross-sectional survey to all departments providing ECMO within 7 United States hospitals in January 2021. One clinician from each department completed the 42-item survey representing their department.

Results: Fourteen departments within 7 hospitals responded (response rate 78%, N = 14/18). The mean time spent consenting patients or surrogate decision-makers for ECMO varied, from 7.5 minutes (95% CI 5-10) for unstable patients to 20 minutes (95% CI 15-30) for stable patients (p = 0.0001). Few clinician respondents (29%) report patients or surrogate decision-makers always possess informed consent for ECMO. Most departments (92%) have absolute exclusion criteria for ECMO such as older age (43%, cutoffs ranging from 60-75 years), active malignancy (36%), and elevated body mass index (29%). A significant minority of departments (29%) do not always offer the option to withdraw ECMO to patients or surrogate decision-makers. For patients who cannot be liberated from ECMO and are ineligible for heart or lung transplant, 36% of departments would recommend the patient be removed from ECMO and 64% would continue ECMO support.

Conclusion: Adequate informed consent for ECMO is a major ethical challenge, and the content of these discussions varies. Use of categorical exclusion criteria and withdrawal of ECMO if a patient cannot be liberated from it differ among departments and institutions.

Keywords: ethics; extracorporeal membrane oxygenation; informed consent; withdrawal of life-sustaining treatment.

Figure 1.

Time spent acquiring informed consent for ECMO. ^aPatient expected survival greater than 24 hour. ^bPatient expected survival less than 1 hour. *P = 0.0001. Bars identify median and 95% confidence interval.

Figure 2.

Patient and decision-maker knowledge and values for care. ECMO, extracorporeal membrane oxygenation.

Figure 3.

Discussion of a time limited trial should be included in the informed consent discussion for ECMO. ECMO, extracorporeal membrane oxygenation; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease 2019.

Figure 4.

Recommended care for patients who cannot be liberated from ECMO. ECMO, extracorporeal membrane oxygenation. Full question: A 60-year-old patient was placed on venovenous ECMO 6 months ago for hypoxic respiratory failure. Imaging shows significant lung fibrosis. The patient is declared ineligible for lung transplant due to poor social support. The patient is awake and alert and reports his current quality of life is acceptable to him. Multiple attempts have been made to wean the patient from ECMO support without success. You believe the patient will never be successfully weaned from ECMO or eligible for lung transplant. In this situation, which of the following actions should be taken. ^aRecommend removing the patient from ECMO as the patient’s condition will not improve and it is unjust to continue providing ECMO when other patients could benefit from access to medical care. ^bInform the patient you will continue ECMO support, but there will be no escalation of medical care (no circuit exchange or addition of pressors, antibiotics etc.). ^cMaintain the patient on ECMO including escalation of support (increasing sweep, adding pressors, adding antibiotics), but informing the patient if the circuit or oxygenator fails, the device will not be exchanged. ^dMaintain the patient on ECMO including escalation of support (circuit or component exchanges, increasing sweep, adding pressors, adding antibiotics) if condition declines.