Almost a decade after ACEP Now published a piece on the ethical considerations of extracorporeal membrane oxygenation (ECMO),¹ its use continues to expand. Ethical quandaries, however, remain.

ECMO can artificially perform the function of a patient’s heart or lungs using large cannulas and a membrane oxygenator to remove carbon dioxide and oxygenate the blood. This is useful in cases of refractory cardiac or respiratory failure, bypassing the native heart or lungs to allow time to recover.² In the emergency department (ED), ECMO has emerged as an adjunct in the resuscitation of patients from acute cardiopulmonary failure. Ideally, ECMO serves a short-term, life-saving purpose. However, ethical issues occur when ECMO becomes a “bridge to nowhere” for patients who are unable to survive without it.^3,4,5 In this article, we identify unique questions associated with using ECMO as a life-sustaining intervention, consider how this technology complicates the current medicolegal definition of death, and describe concerns about the feasibility of rapid expansion of ECMO implementation.

The Ethics of ECMO

At first glance, ECMO appears to present the same ethical challenges as other life-sustaining technologies. The general ethical parameters of initiating and removing ventilatory or vasopressor support are well accepted. ECMO is different from these resuscitative technologies in multiple ways. Patients cannulated on ECMO can live without a functioning heart or lungs. Although patients with ventricular assist devices (VAD) similarly live without a fully functioning heart, these patients ultimately can leave the hospital. Patients on ECMO cannot, at present, survive outside the intensive care unit. Finally, although intubated patients typically require sedation and patients with significant vasopressor support tend to be quite debilitated, ECMO patients can be completely alert and even relatively robust.

As a result, a patient with capacity who decides they no longer want ECMO presents clinicians with the uncomfortable task of discontinuing life support on a patient who is still able to engage and communicate. Although ethically justifiable, this introduces an element of moral distress that may not be present when clinicians discontinue such interventions for an incapacitated patient. Alternatively, patients may want to continue ECMO support despite there being no prospect of recovery, raising questions about whether ECMO can be discontinued over a patient’s objection.⁶

Determination of Death

The Uniform Determination of Death Act (UDDA)⁷ states that an individual is dead if they have sustained “irreversible cessation of circulatory and respiratory functions.” As ECMO can replace these functions, a patient may have circulatory and respiratory organs that are irreversibly nonfunctional but maintain adequate oxygen perfusion for the patient to remain alive. Therefore, it is possible to delay death for a patient on ECMO indefinitely until they meet criteria for neurological death.