Judgment Under Uncertainty: A Case-Based Analysis of Cognitive Bias in Extracorporeal Membrane Oxygenation Candidacy...

There is no consensus for identifying ideal candidates for extracorporeal membrane oxygenation (ECMO), a life-sustaining technology that can supply oxygenated blood to a patient whose heart and/or lungs are not properly functioning. Without clear and standardized guidelines, the decision about who to cannulate often falls upon 1 or several clinicians who weigh the procedure's risks and benefits. Limited data, and therefore substantial clinical judgment, guides ECMO candidacy determination, rendering the process particularly susceptible to heuristic-based decision-making and cognitive biases resulting from mental shortcuts. This can lead to candidates being inappropriately accepted or declined for ECMO and suboptimal allocation of a limited resource. This article presents a hypothetical case based on real clinical scenarios highlighting the impact that cognitive biases may play in ECMO candidacy and discussing their potential harms. We argue that ECMO candidacy determination is especially vulnerable to cognitive biases and offer several ways to mitigate their influence on candidacy selection. Our aim was to stimulate the recognition and mitigation of cognitive bias in ECMO deliberations as 1 step toward the standardization of ECMO candidacy determinations, with the goal of achieving more equitable and effective care for patients who would most benefit from this technology.