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.

Thus, in most ECMO cases, the timing of a patient’s death is a matter of choice, not chance. This decision can be burdensome and even traumatic for patients, families, and medical team members. Furthermore, it can be challenging for health care team members to manage expectations surrounding declaration of death, raising the question of whether consensus-based and universal discontinuation criteria should be established.

Conceptually, routine use of ECMO would pose a challenge to the UDDA’s criterion that cessation of function must be irreversible. The loss of circulatory and respiratory function is always reversible with ECMO. As a result, it may be nearly impossible for a patient to meet a strict interpretation of the UDDA’s guideline for declaring cardiopulmonary death. Some scholars advocate interpreting “irreversibility” not as physiologic irreversibility but as practical irreversibility, i.e., physicians will not intervene once the heart stops. This debate has taken on new urgency as the use of ECMO in organ procurement increases, a process referred to as normothermic regional perfusion; there have been calls to revise the UDDA to address these perceived flaws.⁸

Expanded Use of ECMO

If an expansive approach to ECMO could improve management of patients with cardiac arrest, should we not embrace and encourage its implementation? This futuristic hypothetical must be accompanied by a sober understanding of the actual costs. For instance, innovation and scaling production of ECMO technology itself seems feasible, but given existing problems with staffing and labor costs, the additional personnel burdens will stress an already struggling health care system.

Another challenge would be supporting the population of patients who survive cardiac arrest via these technologies. There are no non-hospital, long-term care facilities capable of caring for ECMO patients. The dramatic increase in in-patient space required to care for such a population could tax an already overextended system, compromising the quality of care for all patients.

Further, one must consider the social and psychological repercussions for patients and families in the setting of complete dependence on ECMO. Patients and families are placed in an uncomfortable position when asked to make decisions about life and death in a space where we, as experts, have not yet reached consensus.

Conclusion

We have argued that ECMO is not just another life-sustaining treatment; it brings up new ethical and practical issues, challenges accepted definitions of death, and may exacerbate existing strains on the health care system. These concerns are relevant to emergency physicians as the expansion of ECMO to our emergency medical systems is actively being considered. Although the routine use of ECMO is appealing, in our view, we are not ready for it. We must address the challenging ethical issues of ECMO being a “bridge to nowhere” by creating public-deliberation-based, consensus-driven protocols for when starting and stopping the circuit are ethically justified. We must develop a coherent definition of what constitutes death on ECMO and educate families, patients, clinicians, bioethicists, and relevant stakeholders about its implications. And we must plan for how ECMO’s expansion into our clinical environment will affect the resources we have to treat other patients.

Dr. Chao is a clinical instructor of emergency medicine and health care ethics fellow at Michigan Medicine in Ann Arbor, Mich.

Dr. Hall is an assistant professor of emergency medicine and cardiothoracic critical care, New York University Grossman School of Medicine in New York, N.Y.

Dr. Malek is a professor of medical ethics at Baylor College of Medicine in Houston, Texas.

Dr. Padela is a professor of emergency medicine of bioethics and the medical humanities and vice chair of research and scholarship in emergency medicine at Medical College of Wisconsin in Milwaukee, Wisc.

Dr. Simon is a professor of emergency medicine at Columbia University in New York, N.Y.

References

1. Allen NG, Jesus J, Knowles H, et al. Extracorporeal membrane oxygenation in the ED: exciting medicine, ethical challenges. ACEP Now. https://www.acepnow.com/ecmo-ed-exciting-medicine-ethical-challenges/. Published on July 19, 2016. Accessed January 10, 2025.
2. Wrisinger WC, Thompson SL. Basics of extracorporeal membrane oxygenation. Surg Clin North Am. 2022;102(1):23-35.
3. Ouyang H. The race to reinvent CPR. The New York Times. https://www.nytimes.com/2024/03/27/magazine/ecpr-cardiac-arrest-cpr.html. Published on March 27, 2024. Accessed January 10, 2025.
4. Dalton C. How ECMO is redefining death. The New Yorker. https://www.newyorker.com/science/annals-of-medicine/how-ecmo-is-redefining-death. Published April 30, 2024. Accessed January 10, 2025.
5. Derse AR. The ECMO bridge and 5 paths. AJOB. 2023;23(6):1-4. doi:10.1080/15265161.2023.2202611
6. Childress A, Bibler T, Moore B, et al. From bridge to destination? Ethical considerations related to withdrawal of ECMO support over the objections of capacitated patients. AJOB. 2023;23(6):5-17.
7. National Conference of Commissioners on Uniform State Laws. Uniform Determination of Death Act; 1980.
8. Lewis A. New reasons to revise the UDDA: controversies related to death by circulatory-respiratory criteria. AJOB. 2024;24(6):44-46.