Ethical factors determining ECMO allocation during the COVID-19 pandemic

Area of Science:

• Critical Care Medicine
• Medical Ethics
• Public Health

Background:

• Extracorporeal Membrane Oxygenation (ECMO) is a scarce resource, particularly during the COVID-19 pandemic.
• Ethical considerations for ECMO allocation may differ significantly from pre-pandemic norms.
• Limited literature exists on pre-pandemic ethical factors in ECMO allocation, with recent focus on other critical care resources.

Purpose of the Study:

• To explore ECMO clinicians' views on ethical factors in ECMO allocation before and during the COVID-19 pandemic.
• To compare the prioritization of ethical factors in ECMO decision-making during the pandemic versus usual times.
• To assess adherence of current ECMO allocation guidelines and practices to pandemic-specific ethical recommendations.

Main Methods:

• An international online survey was conducted with 48 ECMO clinicians from the ECMOCard study group.
• Data were collected between mid-May and mid-August 2020.
• The survey compared the ethical weight given to various factors in ECMO allocation prior to and during the pandemic.

Main Results:

• During the pandemic, clinicians gave more ethical weight to the benefit of ECMO for future patients compared to those already on ECMO (p < 0.001).
• Consideration of discontinuing ECMO for current low-survival patients increased during the pandemic (53% vs. 33% prior, p = 0.002).
• A majority of participants would continue ECMO if the clinical team recommended cessation but the family disagreed, both during the pandemic (56%) and usually (67%).

Conclusions:

• The COVID-19 pandemic led to shifts in the prioritization of ethical factors for ECMO allocation.
• Surveyed clinicians' prioritized ethical principles aligned with established ECMO allocation guidelines and pandemic-related recommendations for life-sustaining treatment rationing.