DNR and ECMO: a paradox worth exploring

Extracorporeal membrane oxygenation (ECMO) provides continuous circulation and/or oxygenation to adults with cardiac failure, pulmonary dysfunction, or both. The technology is similar to the traditional heart-lung bypass machines used during surgical procedures, however ECMO may be used outside the confines of the operating room and for extended periods of time. This paper explores the complexities, both clinical and ethical, of a do-not-resuscitate (DNR) order for patients with cardiopulmonary failure on veno-arterial (VA-ECMO), a type of ECMO that provides resuscitation superior to the chest compressions that DNR is intended to prevent. Clinically, a DNR order has limited utility for patients on VA-ECMO and its presence can serve to create confusion. Symbolically, however, the designation may serve as a stepping-stone for surrogates facing difficult end-of-life decisions. The paper concludes by suggesting that it is prudent to avoid DNR discussions in the context of VA-ECMO