Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults

Extracorporeal membrane oxygenation (ECMO) can serve as a bridge to recovery in cases of acute reversible illness, a bridge to transplantation in circumstances of irreversible cardiac or respiratory failure, a bridge to ventricular assist device therapy in select cases of cardiac failure, or a bridge to decision when the prognosis remains uncertain. Recent advances in ECMO technology that allow for prolonged support with decreased complications, the development of mobile ECMO teams, the rapidity of initiation, and the growing body of evidence, much of which remains controversial, have led to a significant increase in the use of ECMO worldwide. This increasing use of a technology that is not a destination device in itself introduces many ethical dilemmas specific to this technology. In this article, we explore some of the ethical issues inherent in the decisions surrounding the initiation and withdrawal of ECMO by raising key questions and providing a framework for clinicians. We will address extracorporeal cardiopulmonary resuscitation, the inability to bridge a patient to transplant or recovery--the so-called "bridge to nowhere"--and the significance of resuscitation preferences in the setting of continual extracorporeal circulatory support.