Furthermore, ECPR introduces new complexity to end-of-life care discussions and preference documents. Currently, ECPR shouldn’t be presented as a choice/default option that patients ought to consider. Rather, emergency physicians should determine patient goals and formulate recommendations based on those goals and the likelihood that a particular patient will benefit.

While decisions to discontinue ECMO are unlikely to be made in the emergency department, when they are, they should be based on patient preferences, prognosis, and resource use. Discussion of goals, preferences, and the possibility of bridge-to-nowhere scenarios should happen early on. These discussions may also need to look at separate patient preferences: those while their body is capable of functioning without life support and those when their body is completely dependent on artificial life support.

Budgetary Concerns

Beyond the ethical issues surrounding both initiation and termination of ECLS/ECPR, there are serious economic concerns for health systems, including federal and state budgets. Stewardship, rationing, and cost issues are among the major ethical concerns of our day. Principle 9 of the ACEP Code of Ethics refers to our individual and collective duty to steward resources because health care is truly a limited resource. Trauma systems didn’t show real system-wide benefit for several decades; ECLS centers, while exciting, aren’t likely to show similar system-wide value anytime soon.
ECPR was born of the desire to save “hearts too good to die.” An ECPR value proposition will be harder to prove in systems that largely care for older chronically ill patients. In areas with a critical mass of relatively healthy cardiopulmonary arrest patients, the cost per quality adjusted life year may be a more compelling measurement for the value of the treatment.

Of related concern are equity and the “ZIP-code lottery.” Affluent systems may be able to offer ECLS-type resuscitative techniques, while other systems cannot, exacerbating inequitable health care delivery. Beyond our role as resuscitation experts, we have a parallel obligation to advise policymakers to be prudent stewards who are neither too quick nor too slow to embrace new cost-effective technologies and techniques like these.

In addition to system costs, there are practical resource concerns when considering ECMO initiation in the emergency department. ECPR initiation and delivery require a local team that’s ready, willing, and able to rapidly respond. The three-stage protocol for ED physician-initiated ECMO reported by Bellezzo et al typically involves the use of two ED physicians (one to manage the resuscitation and the other to perform ECPR initiation procedures) and relies on the availability of an emergency critical care nurse response team trained in the initial operation of portable ECMO equipment.3 In Bellezzo’s model, focused training was provided for ED clinicians on ECMO initiation, and skills were maintained through ongoing education. This level of human resource commitment is impractical for most emergency departments, not to mention that it’s unlikely to be reimbursed by grateful families, patients, the Centers for Medicare & Medicaid Services, Medicaid, or any other payer.