Compassionate Extracorporeal Membrane Oxygenation Discontinuation: A Narrative Review and Practical Process Model for...

Area of Science:

• Critical Care Medicine
• Palliative Care
• Medical Ethics

Background:

• Extracorporeal membrane oxygenation (ECMO) offers vital support but is not always aligned with patient goals when recovery is not possible.
• Planned withdrawal of ECMO, termed compassionate ECMO discontinuation (CED), is necessary when patients are not transplant or durable mechanical support candidates.
• CED aims to minimize suffering during end-of-life care, addressing a critical need in intensive care settings.

Purpose of the Study:

• To propose a reliability-oriented framework for standardizing compassionate ECMO discontinuation (CED).
• To reduce preventable distress for patients, families, and clinicians involved in end-of-life ECMO withdrawal.
• To guide clinicians in implementing a structured process for planned ECMO withdrawal.

Main Methods:

• A targeted narrative review of ethical analyses, consensus guidance, and empirical literature on planned ECMO withdrawal was conducted.
• The review findings were integrated with existing practical processes to develop a reliability-oriented framework.
• Recommendations were organized into a four-phase process model, including modality-specific considerations for VA-ECMO, VV-ECMO, and ECPR.

Main Results:

• The proposed framework comprises four phases: Anticipation and Alignment, Preparation, Implementation, and Aftercare and Learning Capture.
• Key elements include structured shared decision-making, palliative care integration, interdisciplinary preparation, comfort-focused implementation, and post-procedure debriefing.
• Specific recommendations address managing disagreement, family coaching, medication adjustments, environmental controls, and learning systems.

Conclusions:

• Standardizing compassionate ECMO discontinuation (CED) through a structured, reliability-oriented process improves goal-concordant end-of-life care.
• Implementing CED with scripts, checklists, and feedback can reduce suffering, family trauma, and clinician burden.
• This framework strengthens ECMO program learning systems and enhances end-of-life care quality.