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

Unique features of extracorporeal membrane oxygenation (ECMO) contribute to ethical dilemmas and decisional complexity. Initiation of ECMO is a growing challenge for providers, families, and centers. We offer 4 practical recommendations for ethically supported, informed decision-making regarding starting ECMO. Recommendations draw on clinical experience, existing literature, and ethical frameworks, and they distinguish between offering ECMO and initiating ECMO within the broader concept of starting ECMO. First, to offer ECMO, clinicians first should determine that support is technically feasible and medically indicated, offering plausible therapeutic benefit by allowing time for recovery or effects of disease-directed therapies. Clinicians have an ethical imperative to make comprehensively reasoned, individualized, and fair decisions. As a result, ECMO decision-making should follow a robust, structured process aligned with principles of procedural fairness to mitigate barriers to high-quality deliberation. If ECMO is offered, clinicians should incorporate patient and family values into the decision to initiate ECMO, providing clinical recommendations within shared decision-making. Second, clinicians must expand consideration of informed consent beyond a single time point. Clinicians should engage in frequent, iterative conversations to achieve informed consent-grounded in the principle of respect for persons-throughout the ECMO course. Clinicians should emphasize ECMO as a temporary, goal-directed intervention during consent discussions to set clear expectations. Third, when ECMO is not offered, the team should document and, as appropriate, communicate the rationale to patients, surrogate decision-makers, and families. Fourth, institutions should establish processes, including a forum to resolve disagreements and measures to capture and share organizational experience, and should promote institutional accountability.