P034: A BRIDGE TO NOWHERE? ETHICAL IMPLICATIONS OF ECMO AS DESTINATION THERAPY
Michelle Lipton, MD, Gavin Divertie, MD; Mayo Clinic
Extracorporeal Membrane Oxygenation (ECMO) has successfully provided circulation and oxygenation in a number of clinical conditions requiring life support until one of three patient outcomes occurs: 1) Clinical improvement. 2) Conversion to destination therapy with the cessation of ECMO. 3) “Bridge to nowhere” scenario when ECMO becomes destination therapy necessitating Intensive Care Unit support until patient expiration. ECMO intrinsically poses ethical concerns, however ECMO as destination therapy poses a uniquely complex ethical dilemma. Such complexity arises when multiple morally acceptable management strategies are in direct conflict. These options include immediate discontinuation of ECMO, indefinite continuation of ECMO, or continuing ECMO under the notion of “no escalation of care”. For this reason, a literature search was performed to better elucidate the key ethical considerations of ECMO destination therapy in order to provide a framework with which clinicians can approach this ethically complex scenario.
A PubMed search was conducted with inclusion of case reports and expert opinion articles highlighting ethical considerations of ECMO, with particular emphasis on ECMO for destination therapy. The majority shared four relevant topics in common: challenges in obtaining informed consent, balancing discordant desires for management strategies, medical futility, and allocation of recourses. Through balancing applied ethical principles of autonomy, beneficence, non-maleficence, justice and Virtue Ethics, authors offered justification for each of the three proposed ECMO management strategies. One can therefore conclude that decision making must be made on a case-by-case basis, however valuable generalizable lessons were provided. Hospitals should develop universal protocols for aspects of care including but not limited to patient eligibility, management, and duration of ECMO therapy. Although challenges exist, informed consent must be attempted with thorough explanation of all possible outcomes including potential discontinuation of ECMO and withdrawal of care. Early inclusion of family members/surrogates may prove critical in avoiding conflict regarding decision making if bridge becomes destination therapy. If conflict does occur, consult with the hospital ethics committee, legal department, palliative care, and/or case management services while reserving court order as a last resort. If care is deemed futile, with the support of the above resources, physicians need not feel obligated to continue care.