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.