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Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations

      Abstract

      Objective

      To describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology.

      Patients and Methods

      We retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation.

      Results

      Of 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death.

      Conclusion

      For most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.

      Abbreviations and Acronyms:

      AD (advance directive), BMCS (bridge to mechanical circulatory support), BTD (bridge to decision), BTT (bridge to transplant), CPR (cardiopulmonary resuscitation), DNR (do not resuscitate), ECMO (extracorporeal membrane oxygenation), ECPR (extracorporeal cardiopulmonary resuscitation), IABP (intra-aortic balloon pump), ICU (intensive care unit), IQR (interquartile range), LST (life-sustaining treatment), MOD (multiple organ dysfunction), VA (venoarterial), VV (venovenous)
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