A previously healthy 45-year-old man is brought into the emergency department with chest pain and arrests immediately upon arrival. You begin advanced cardiovascular life support (ACLS), but after 10 minutes, he remains in cardiac arrest. You remember that extracorporeal membrane oxygenation (ECMO) has just become available at your hospital. Should you consider it for this patient?
ECMO—where oxygen loading of red blood cells and mechanical perfusion with oxygen loading are facilitated outside the body with a portable pump and circuitry hooked up through large vessels—has been used for more than 40 years to provide cardiac and respiratory support to patients who have potentially reversible causes of respiratory/cardiac failure. What began as a temporizing measure for meconium aspiration in neonates has gradually expanded to adult populations. Since 2015, the American Heart Association guidelines have cautiously included ECMO as a resuscitative option.1 The guidelines refer to two options: ECMO used in the emergency medicine setting is extracorporeal life support (ECLS), while ECMO used in the arresting patient is extracorporeal cardiopulmonary resuscitation (ECPR).
Placing an ECMO link in the chain of survival has shown promise for improving outcomes in refractory scenarios with previously healthy candidates. If you consider the use of ECMO, however, you need to be aware of the clinical and ethical considerations of doing so.
The Right Patient
Good ethics is based on good science, and there’s a great need for continued research to identify the best candidates for ECMO in the emergency department since current evidence is from observational studies only. Absent high-quality studies, data from ECMO registries and observational studies support a general short list for clinical consideration. Generally, patients who are eligible:
• Are 18 to 70 years old;
• Have a witnessed arrest;
• Have ventricular fibrillation or ventricular tachycardia as their initial rhythm;
• Have a presumed cardiac cause; and
• Received high-quality CPR delivered with minimal interruptions.
Patients with known cognitive impairment, evidence of multi-organ dysfunction, irreversible causes, do not attempt resuscitation (DNAR/I) status, or prolonged CPR/EMS transport haven’t been shown to benefit from ECLS/ECPR as a temporizing approach and should be considered ineligible.1–5
The decision to proceed with ECMO in the emergency department must be made quickly and with careful determination of how patients will benefit. ECMO should be considered a bridge to recovery (from a specific illness or organ damage), transplant, or other definitive care such as a left ventricular assist device (LVAD). If achieving a definitive recovery point is unlikely, ECMO shouldn’t be used. In these cases, ECMO is not a good use of resources, particularly if the necessary specialists or recovery options aren’t available locally and the patient must be transferred while on ECMO. Additionally, it has the very real potential of prolonging dying at the high cost of patient and family suffering.
Patients considered for ECMO are likely to be critically ill and lack decision-making capacity. When this happens, clinicians may ethically provide care with emergency consent under emergency conditions. Although it isn’t clear that ECMO ought to fall into the category of care provided under emergency consent, Riggs et al argue that ECPR in these cases may be acceptable given that the alternative is to withhold it from those who might benefit and may have consented to the treatment.
Bridge to Nowhere
Because it isn’t a definitive treatment, ECMO has the awful potential to commit a patient and family to a “bridge to nowhere,” an unthinkable scenario in which the patient is alive and functioning but confined to continued treatment in an ICU with no hope for ECMO discontinuation, transition to a definitive therapy, or discharge home. Decisions to discontinue care will be difficult because there isn’t a clearly established failure point such as cessation of cardiac activity; discontinuation ultimately may need to be determined by gradual multi-organ failure.