Starting Extracorporeal Membrane Oxygenation: A Review of the Ethical Issues and Recommended Approach

Area of Science:

• Critical Care Medicine
• Medical Ethics

Background:

• Extracorporeal membrane oxygenation (ECMO) presents unique ethical challenges and decisional complexity.
• Initiating ECMO is increasingly difficult for healthcare providers, families, and institutions.

Purpose of the Study:

• To provide four practical recommendations for ethically supported, informed decision-making regarding the initiation of ECMO.
• To distinguish between offering ECMO and initiating ECMO within the broader concept of 'starting ECMO'.

Main Methods:

• Recommendations are based on clinical experience, existing literature, and ethical frameworks.
• The study outlines a structured decision-making process for offering and initiating ECMO.
• Emphasis is placed on shared decision-making, incorporating patient and family values.

Main Results:

• ECMO offers should be technically feasible, medically indicated, and provide plausible therapeutic benefit.
• Informed consent for ECMO must be an iterative process throughout the treatment course.
• Clear communication of rationale is essential when ECMO is not offered.

Conclusions:

• Institutions need robust processes for ECMO decision-making, including disagreement resolution and accountability.
• Ethical considerations are paramount in ECMO initiation, requiring procedural fairness and respect for persons.
• Emphasizing ECMO as a temporary, goal-directed intervention manages expectations effectively.