Ethicists are asked to help resolve decisions on whether to continue extracorporeal membrane oxygenation (ECMO) support when a cure is no longer possible, for both incapacitated and capacitated patients.1,2 Andrew Childress, PhD, has been involved in several of these difficult cases. “The literature has mainly focused on what to do if surrogate decision-makers object to the withdrawal of life-sustaining interventions,” notes Childress, an assistant professor at the Center for Medical Ethics and Health Policy at the Baylor College of Medicine.
However, some of the consults involved the patient’s objection. In a recently published paper, Childress and colleagues argued that commonly used ethical justifications for unilateral withdrawal over the objection of a patient with decision-making capacity are problematic.3 “We saw an opportunity to explore an area of decision-making that others have highlighted, but not examined thoroughly,” Childress explains.
Some patients had a poor prognosis for recovery, and were not a viable candidate for transplant. Still, patients or family requested continued ECMO support. Ethical considerations in those cases include resource allocation, quality of life, patients’ rights, the ethical equivalence of withholding and withdrawing life-sustaining interventions, and professional integrity. “These arguments may seem persuasive at first glance, but we draw out some contradictions and poorly supported assumptions that weaken most of them substantially,” Childress reports.
Cases involving differences of opinion about ECMO goals are challenging for healthcare professionals, families, and patients. “The ethicists’ task is to help stakeholders examine the underlying assumptions in light of the available empirical evidence or potential counterarguments,” Childress says.
Ethicists approach each conversation with the intent to help clarify the value conflict involved and facilitate a resolution of the conflict in a respectful, compassionate manner. “Our goal in the paper was to provide a thorough examination of some of the ethical considerations involved in these cases, with the hope that fellow ethicists, administrators, and our clinical colleagues might consider these issues as they create guidance, policies, and care plans at the bedside,” Childress says.
There is much debate over what situations, if any, make it ethical for clinicians to choose to withdraw ECMO over the objection of a patient or surrogate, says Gina Piscitello, MD, MS, assistant professor of medicine at Rush Medical College and a medical ethics consultant at Rush University Medical Center in Chicago.
Piscitello was lead author of a survey of 14 clinicians about ECMO in clinical practice. The authors found 29% of departments do not always offer the option to withdraw ECMO.4 If patients cannot be liberated from ECMO and are not eligible for transplant, 36% of departments would recommend withdrawing ECMO and 64% would continue ECMO. “Reasons clinicians may choose to unilaterally withdraw ECMO from a patient include concern that the harms of ECMO outweigh the benefits,” Piscitello notes.
An example would be a patient on ECMO who cannot wake up and does not have adequate blood flow to their extremities, causing their tissues in their hands and feet to die and turn black. “In this case, there could be concern the patient is suffering and that ECMO is unnaturally lengthening and worsening the dying process,” Piscitello says.
Still, some clinicians and ethicists argue unilaterally withdrawing ECMO over a patient or surrogate objection is never ethical. “Support for this viewpoint includes [the fact] clinicians have an obligation to provide care to patients that is medically beneficial for them based on the preferences of the patient,” Piscitello says.
This is consistent with how care is provided for patients on other types of life support that are routinely provided in the United States, such as mechanical ventilation and dialysis, according to Piscitello. Piscitello says ethicists can help in cases involving conflict over withdrawal of ECMO by ensuring communication among the patient, surrogate, and medical team is open and transparent. They can encourage societies to develop guidelines for how these cases should be approached to ensure all patients receive the same access and quality of care.
Ethicists also can track how often these cases occur, evaluating for disparities in the use of unilateral withdrawal of ECMO, and help develop interventions to improve any disparities found.
A life-sustaining treatment should be withdrawn over the objections of the family when continuing treatment violates the patient’s previously expressed values, goals, and preferences, according to Paul S. Mueller, MD, MPH, professor of medicine and biomedical ethics at Mayo Clinic College of Medicine and Science. Families and surrogates are ethically and legally obligated to make decisions based on the patient’s previously expressed wishes. “When these are unknown, decisions should be made based on what is in the patient’s best interests,” Mueller says.
Clinicians also are ethically obligated to withdraw life-sustaining treatments that are completely non-beneficial, Mueller adds. Many patients who receive ECMO do so at a time when the likelihood of recovery is uncertain.5 Such cases include postcardiotomy patients who cannot wean from cardiopulmonary bypass after surgery. In some cases, despite receiving ECMO, clinicians determine the patient is no longer a candidate for transplant or an artificial heart, and never will recover.
“ECMO becomes a ‘bridge to nowhere,’ where the patient is receiving indefinite ECMO support,” Mueller explains.
Even so, the patients or their surrogates might perceive benefit from ongoing ECMO support. “Some ethicists argue that under such circumstances, withdrawal of life-sustaining treatment against the patient’s wishes would deny a ‘good’ death, such as more time to make a decision, and might result in emotional suffering,” Mueller says.
Patients might regard their quality of life as good and ECMO “destination therapy” as acceptable. “This situation raises the question whether ECMO should be offered to patients with end-stage organ dysfunction in order to extend survival, but are denied ECMO under current standards, as they are not eligible for transplant or other definitive treatment,” Mueller notes.
Typically, once started, life-sustaining treatments are not withdrawn from patients against their wishes (or a surrogate’s wishes) if ongoing treatment is perceived as beneficial; the benefits are perceived to outweigh the burdens; and continuing treatment is consistent with the patient’s values, goals, and preferences.
However, Mueller says, ECMO should not be continued when it is no longer clinically effective. For example, a patient may have ongoing circulatory deterioration with no hope for recovery, or the patient becomes dead by brain death criteria, and ECMO is merely maintaining circulation.
In Mueller’s experience, patients for whom decisions to withdraw ECMO were made also were moribund and supported by other life-sustaining treatments. Frequent conversations with family, care conferences that clarify treatment goals, and involvement of spiritual care and palliative care colleagues creates a compassionate and supportive environment. These approaches facilitate conversations about withdrawal of treatment. “This builds trust, lowers emotional distress, and potentially reduces the frequency of ‘objecting family’ scenarios,” Mueller says.
Involving ethics consultants early in ECMO cases can clarify patients’ values, goals, and preferences; family perspectives; medical indications; and quality of life concerns. “This process, alone, can lead to resolution of dilemmas that arise in the care of these patients,” Mueller says.
REFERENCES
1. Wilkinson D, Fraser J, Suen J, et al. Ethical withdrawal of ECMO support over the objections of competent patients. Am J Bioeth 2023;23:27-30.
2. Callies DE. Unilateral ECMO withdrawal and the argument from distributive justice. Am J Bioeth 2023;23:72-74.
3. 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. Am J Bioeth 2023;23:5-17.
4. Piscitello GM, Bermea RS, Stokes JW, et al. Clinician ethical perspectives on extracorporeal membrane oxygenation in practice. Am J Hosp Palliat Care 2022;39:659-666.
5. DeMartino ES, Braus NA, Sulmasy DP, et al. Decisions to withdraw extracorporeal membrane oxygenation support: Patient characteristics and ethical considerations. Mayo Clin Proc 2019;94:620-627.
The commonly used ethical justifications for unilateral withdrawal over the objection of a patient with decision-making capacity are problematic. The ethicists’ task is to help stakeholders examine the underlying assumptions in light of the available empirical evidence or potential counterarguments.
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