SCCM Resource Library-A Bridge Too Far? Controversies in the Initiation and Discontinuation of Extracorporeal Life Support

Video Transcription

Hi, everyone. Welcome to the Congress session on A Bridge Too Far, Controversies in the  Initiation and Discontinuation of Extracorporeal Life Support. I'm going to introduce our speakers  for today. I'm Wynne Morrison. I am a critical care and palliative care attending and ethics consultant at the Children's Hospital of Philadelphia and University of Pennsylvania.  I will be discussing getting on the bridge, ECLS candidacy. Next, we'll have Dan Brody,  who's a professor of medicine at Columbia College of Physicians and Surgeons and director of their  adult ECMO program. He will be discussing getting off the bridge, discontinuation of ECLS.  And next, we have Katie Moynihan, who is a cardiac intensivist at Boston Children's Hospital.  She is the instigator and moderator of our program today, who will be discussing navigating the bridge, approaching decision making, and framing discussions. We will be saving time  for group questions, answers, and discussions at the end. I have no disclosures. My topic is  getting on the bridge or ECLS candidacy. And throughout, I will probably use ECLS and ECMO  interchangeably, but talking in general about extracorporeal support. And I like to start with  kind of where we came from to better understand where we are now. The history of using ECMO or  ECLS to support patients really started in the 50s with the advent of cardiopulmonary bypass,  moved then into the 60s with animal models of prolonged bypass, and then early trials in the  60s and 70s, and first in premature infants, who turned out to be not the best population  to try this in because it was almost universally fatal with hemorrhage. But in 1971, there was the  first adult human survivor, and in 1975, the first term neonate survivor. There was a randomized  trial in the mid to late 70s, which, interestingly enough, showed very high mortality in both the  intervention and control groups, more than 90 percent. These early trials led to the therapy  really not being used much in adult patients at all. However, in pediatrics, some early trials,  which were very small and used some interesting adaptive randomization strategies, did show early  promise in children, and that led to the therapy really being adopted in term neonates and in  pediatrics and used for many years. The intervention transitioned back to adult patients  several decades later, and that's part of what we're going to talk about. This was either spurred  by or coincidental with the H1N1 influenza pandemic in 2009, that it was used in more adult patients. Then two large trials also affected practice, one in 2009 in the UK, which was  really in some ways more of a trial of referral to an ECMO center rather than of the intervention itself, but showed promise. Then another large trial in multi-centers with ARDS,  which was stopped early because of futility with not showing any significant benefit.  However, despite not being a statistically significant difference, there were many differences that people noted who looked at this trial, and many crossovers to ECMO. I think even  though it was in some ways a negative trial, it convinced many that this was a therapy worth  trying. It's also important to think back to candidacy and how that has changed over time. When I first started caring for ECMO patients as a trainee over 20 years ago,  every center had its own criteria, but many said we would never put a patient on who had a blood-borne infection like HIV or hepatitis, never put a patient on who had cancer,  would never have a patient on prolonged ECMO, we would not put someone on who'd been on a  ventilator for more than a few days. At that time, very, very few adult centers were even using it  at all. Interestingly, maybe for some of you at that time when we put a patient on ECMO, we had an attending physician come in at that center to staff in-house for that one patient,  and that's probably hard to imagine now. Now it's becoming much more common to use for many  different reasons. If you look at this slide that was a fairly recent study of a national database  of about 20 percent of the national population of inpatient admissions, the green line shows  ECMO admissions over time and showing that they really have in adult patients been increasing  tremendously from 2007 to 2012. The dotted line is mortality, which shows that there have not been trends in either direction in mortality, interestingly, as use has increased.  What are the indications and contraindications? If we go to the Extracorporeal Life Support  Organization website, there are several. This has a wealth of information, but some of this  includes some guidelines for indications and states that ECLS is indicated in acute, severe,  reversible cardiac or respiratory failure when the risk of dying from the primary disease, despite optimal conventional treatment, is high. Relative contraindications are conditions  incompatible with normal life, pre-existing conditions which affect the quality of life,  age, size, and futility. This is, as you can tell, it's noted to be relative, and these are also  things that may be very different as technology changes, may be different as systems of care  change, and also could be impacted by resources available at an institution. That's part of why  they say relative contraindications. It will also be a reason that if you came to this talk  hoping that you were going to get set age cutoffs or comorbidity cutoffs to say this is when ECMO is  indicated or not, you will be disappointed because I will not be giving you that because these things  do vary by systems of care, and they vary with time and with new technology. We often think of  what is ECMO a bridge to, and Dan will talk more about this in a minute, but when we're thinking  about it for ECMO candidacy, our hope is, of course, that it is a bridge to recovery. That's  the gold standard, and that's how we started this therapy, hoping that patients' heart and lung  function could recover and they could return to a condition of health. It's more and more been used  now as a bridge to transplant, and that really does bring a whole different set of patients in  as possible candidates for this therapy and is extending the indications. It's also now being  used as a bridge to alternative support, whether that's long-term ventilation or ventricular assist  device. In addition, it's oftentimes used as a bridge to clarity or a decision, and these are cases where we are starting ECMO. We're not yet sure which of the above endpoints maybe  we are bridging to or maybe if any of them were possible at all.  And then in very rare cases, I've seen ECMO used as a bridge to saying goodbye. This is the idea that it may be reasonable to continue for a short amount of time to let family  gathers say goodbye to a patient. I've seen this in cases where ECMO has been put in place in the  OR, but it becomes apparent that it's not going to be able to save the patient, but we bring the  patient back to the ICU for a very time-limited period to let the family hold the child as they  are dying. And then the other controversial area is organ donation and whether it's appropriate to use ECMO as a bridge to organ donation. This is controversial when ECMO is started  only for the purpose of donation, and that's more than we can get into in this talk, but it's also the case that when ECMO has been started to try to save the patient and it has  become apparent that we won't be able to do so, that we can sometimes use it as a bridge to be able to offer donation if that's what the patient and the family would want.  One important point in thinking about who is an ECMO candidate is that I really do believe that  there is strong ethical justification for the medical team owning the determination of who is  an appropriate candidate and deciding when to offer this to patient and family. And there, of course, are important patient and family goals and values, which may determine whether  they decide to accept that potential plan. But the reasons that it's appropriate for the medical  team to decide who's a candidate are that it's a highly technical, invasive, and resource-intensive  treatment. Decisions are often made only in urgent and emergent situations, so there are constraints  on being able to fully inform the patient or family. It should be targeted to those with  the best chance of a good outcome, especially when there are limitations on how many patients we can offer it to. The decision absolutely needs to be individualized to the patient,  but we need to make sure it's not capricious. So it should be, individual patient factors should  be considered, but an individual clinician should not be making an arbitrary decision about who's  a candidate. I do believe that there is no requirement to mention ECMO to those who are not candidates unless ECMO has become standard of care for patients in similar circumstances,  where that might affect our obligation to mention it to those who we have determined for some reason  are not candidates. So I wanted to briefly talk about a couple of special circumstances which  could impact who are candidates and how we make these decisions. One is the advent of eCPR,  or ECMO CPR, in the setting of cardiac arrest. One reason this has shifted the way we think  about things is this is almost always done in an emergent or urgent situation. My photo here,  which is one of my favorites, is a photo of a patient being cannulated for ECMO on the floor  of the Louvre, and there are even mobile ECMO programs being developed in many countries where  instead of bringing the patient to ECMO at the institution, they bring the ECMO to the patient  in the field for cardiac arrest. And this absolutely changes because in an acute situation  like this, it's rare that we actually know a full history of the patient's comorbidities. We may not  even know the patient age, and we're having to make decisions about whether to institute a therapy  at the same time that we are gathering all of this information. And so candidacy is different.  It also changes the discussion, and Katie will be talking more about discussions later,  but it really changes how we have the discussions when the therapy's already been put in place  emergently. And eCPR is still being studied. There are trials ongoing in France and England.  One U.S. trial that was conducted recently, which really does show the feasibility of using this,  was a study in the emergency department of randomizing patients to eCPR versus standard  ACLS protocols when they arrived in full cardiac arrest. And this study did show that there was improved survival and improved neurologic, good neurologic outcome  with eCLS. The authors make the very important point that this was in a mature ECMO program with really good systems of care in place, and that these outcomes would not  necessarily be easily mimicked elsewhere without a lot of work put into the system.  The other circumstance, it's a special circumstance I wanted to talk about, is the impact of COVID-19 and the pandemic. I think this impacts who ECMO candidates are in two different  ways. One is the question of risk versus benefit, and the other scenario is the question of scarcity, and these are distinct, and I want to make this point. In a pandemic situation,  risk-benefit does change for the individual patient, and one way that changes is due to risk to staff, potentially. If you imagine a thought experiment in a different pandemic,  if we were dealing with something like Ebola, it might affect whether we would decide to take patients emergently with CPR underway from the ED to the cath lab and cannulate them,  if that had a chance of exposing multiple staff members and multiple other patients.  COVID is obviously not as risky as that, and so as we learn more about the disease, as we think  about what the interventions are, institutions will have to make decisions about how much risk  is worth taking. The other situation is scarcity. If we are in a situation we hope that we won't be,  we hope we won't have to ration ICU beds or ventilators, although I know there are capacity strains we see with COVID right now, ECMO circuits are probably more likely to be in  limited supply than ventilators or ICU beds, and so we may have to face these decisions,  and many institutions are starting to think about this and realize it's not just the equipment.  It's also staff. It is blood supply. It is PPE. There are many other things that may be affected.  This is a different circumstance than the risk-benefit situation.  One important study was done, which does show that ECMO is worth trying in COVID-19 and many  COVID-19 patients. It showed that there were more survivors, actually, than those who died.  Long-term implications are going to be important to follow up to determine what neurologic outcome  is and what long-term life is like for these patients, but these are important studies to do.  And another important statement available on the ELSO website looks at setting guidelines in times  of scarcity. Dan participated in many of these discussions, and I'm sure he can enlighten us  further in discussion, but they had a great figure in this paper looking at capacity strain and  contingency planning and making a very clear point that it's not all or none. When you have resources  available, you're going to look at both your COVID patients and your non-COVID patients with a different eye than when you're in a crisis situation. We should not assume we're in a  crisis situation when we are not, and there are different tiers here. And again, it's really  important to note that the definition of what is reversible and what is not reversible really does  depend on what your system of care is at your institution and in the full healthcare system where you are working. So in summary, our guiding principles for patient selection,  it's very important to be both equitable and judicious. We should carefully select patients,  but we should make sure that all are offered equal chances of being chosen if they are in  the same circumstances. We should target those most likely to benefit. Resources and capacity  can justify altering standards. We should be aware of changing outcomes with time. And as we  learn more about both technology and the disease processes we're treating, we should make sure that  we learn from what we do and that directiveness regarding who is an ECMO candidate is ethically  justifiable. Thank you. I want to thank the organizers for inviting me to speak today. As you heard in the last talk from Dr. Morrison about getting on the bridge, we will now talk  about getting off the bridge, discontinuation of extracorporeal life support. These are my  disclosures. The only one relevant to this talk is that I chair the International ECMO Network,  and one of our studies will appear at the end of this presentation. If you haven't seen this,  this is a terrific issue of JAMA from 2016 where they talked about death, dying, and the end of  life. One of the articles by Derek Angus and Bob Trug called Toward Better ICU Use at the End of  Life has this really terrific quote. They say that the goal of ICU care is to help patients improve  and be discharged, not merely to sustain life. When we lose sight of this principle, ICU has  become, and this is really the key, ICU has become a destination therapy, and care is continued until  life can no longer be sustained. That's really a terrific quote, this idea of ICUs as a destination  therapy when we lose sight of what we're really trying to achieve. It really brings up this  concept of the role of life-sustaining technologies in the ICU. This is from a paper we wrote in the  AMA Journal of Ethics on the appropriate use of increasingly sophisticated life-sustaining  technology. We said the fact that we have the ability to sustain organ function does not mean  that it is always medically or ethically appropriate to do so. Of course, doing so requires  judgment, and we go on to say that it would be inappropriate to use these technologies, technologies  like ECLS, only to prolong the dying process and critically ill patients with low quality of life  and no chances of achieving any of their goals. So how do we begin to exercise that judgment?  It really requires an understanding of what is ECMO capable of, and ECMO is not a treatment as  we all know. It's a support device and it acts as a bridge, and that can be a bridge as you see  here either on the left to recovery, a bridge to transplant, a bridge to left ventricular assist  device in cardiac patients, or potentially a bridge to decision when we're not sure if the patient will recover or will require either transplant or an LVAD. So it's initiated as a  bridge as you heard previously to recovery, transplant, VAD, or decision, but what if the patient  is initiated and now there's no hope of recovery? There's no possibility of transplant or VAD, and so  at that point ECMO becomes a bridge. It's the so-called bridge to nowhere. So the patient may be  very much alive but totally dependent on ECMO and with very few exceptions unable to leave  the intensive care unit, which very much limits what our goals can be. Sort of like a state of  suspended animation in a way, and to begin to conceive of this my good friend and colleague  Thomas Beinlund said, why is it so hard to die now? Have we interrupted the biologic process  of dying with extracorporeal machines? So how should we approach these discussions in our ECMO patients? Well I think most importantly, comprehensively and as a team, and we often  think of that team as involving doctors and nurses and advanced practice practitioners, but  often the most important members of the team in these discussions are palliative care colleagues,  pastoral care, ethics, social work, and in fact through building relationships with the patients it may be a physical therapist, an occupational therapist, a respiratory therapist,  maybe the environmental services or nutritionists who often can really relate to the patients and  bring out key aspects of what their goals of care are. It really is about building relationships.  In this paper on treatment limitations in the era of ECMO we talked about a couple of concepts  and we tried to understand how do we decide when to offer high-risk, resource-intense interventions, getting on the bridge, but also how do we decide when to withhold or withdraw  them? How do we get off the bridge? A couple of the concepts include shared decision-making in the ICU, this really nice paper by Randy Curtis who speaks eloquently about this,  and time-limited trials. Time-limited trials are very simply the patient improves and the therapy  continues, but if the patient deteriorates, therapy may be withdrawn. Going back to the article by Derek Angus and Bob Trug, they also said that treatment in the ICU must be seen as  a trial of therapy and not an open-ended commitment to a particular ongoing level of treatment, and that really is the concept of a time-limited trial.  There's a particular role on the teams that I'd like to highlight. This is the role of spiritual care in the intensive care unit. This is a paper by my colleagues Joel Burning  and Matt Baldwin, and it was the effect of a chaplain-led picture-guided spiritual care. This is for patients who are having difficulty communicating because they were on a base  of mechanical ventilation within the ICU. This is in adults, and Joel and his colleagues had  created this really terrific spiritual care guide that patients could point to. On the left,  you see they could point to various feelings, everything from being afraid or sad to excited  or hopeless. On the right, they could point out things that they might want, either to pray or  to have someone hold their hand. Could you get my nurse? Then at the bottom on the left,  you can see this concept of spiritual pain that they created. Really on a scale from 1 to 10,  we weren't sure if patients would understand the idea of even rating their spiritual pain, but they did, and actually most patients related very well to that concept.  On the back of the card allows patients to identify either their religion or not having  a religion or they don't know or prefer not to say. This was a very powerful tool that we started  to use in our ICU, and in this study, they were able to demonstrate a decrease in anxiety in  patients based on using this card with their chaplain. What do physicians think going on to  that part of the team? There's this study from the ECMO-Net by my colleagues Daryl Abrams and Mathieu Schmidt, among others, and this is practice patterns and ethical considerations  in the management of venovenous extracorporeal membrane oxygenation patients. This is an  international survey. It was scenario-based, so giving cases that illustrated various aspects  of care that brought up some of the important ethical issues. It looked at physician practices  for initiation, limitation, and importantly for us in this talk, withdrawal of venovenous ECMO.  It was conducted at extracorporeal life support organizations, ELSO centers, and ECMO-Net centers,  ultimately there were 539 physicians who filled this out from 39 countries across six continents.  Looking first at factors that would make respondents reluctant to initiate ECMO,  some of the things you might imagine, older age was one of them. 70 and 75 were the most commonly  chosen upper limits for that. Presence of other organ failures might make people hesitant to  initiate ECMO. Mechanical ventilation over seven days prior to ECMO and then prone positioning had  not yet been attempted, although only 21% identified no prone positioning as a limiting  factor for initiating. Looking now at factors most likely to influence the decision to withdraw  ECMO support, these were the main ones, patient comorbidities, patient's wishes, etiology of the  respiratory failure, and the patient's age, so the things that might impact on prognosis but also  very importantly the patient's own wishes should they be known. In this study more than 90% of  respondents indicated that management decisions always or very often are made in consultation  with other physicians, but fewer than 30% said they were always or very often involving nurses in ECMO decision making, which is clearly an opportunity for all of us.  About 50% agreed that ethics consultation was important when making decisions regarding  withdrawal, and about two-thirds at the time of initiating ECMO said they always or very often  discussed the possibility of ECMO withdrawal in cases of futility, so at the point of initiation  having that discussion ahead of time. So what recommendations can we make when approaching this very difficult series of discussions and approaching these patients in a humane way?  One is to have in the first place strict criteria for initiation so that you avoid creating  unnecessary situations whereby the patient may be a bridge to nowhere because they were not  appropriate and were not going to be able to be supported for recovery or transplant or VAD with  ECMO. Engage the patient in surrogates in an honest dialogue of the potential and the limitations of ECMO whenever feasible prior to initiation, and often obviously that's with  surrogates but not always. Provide multidisciplinary support, as I've said that's really a constant  theme for those who provide this kind of care is the need for involving all of our colleagues  across the spectrum who can contribute to helping our patients. And then of course particularly for  the bridge to nowhere, and when the patient is awake, whether or not they have capacity but they are awake and participatory, managing symptoms is really key in maximizing quality  of life, so treating pain and anxiety, minimizing testing and invasive monitoring, reducing noise  and light pollution, and of course as desired by the patient, facilitating family and surrogate  interactions. Obviously we want to respect the preferences and treatment goals of our patients  or their surrogates. Assess and address spiritual pain, that is a newer concept obviously,  but something that is probably a great opportunity in helping our patients. Give clear guidance on  prognosis and alternate treatment options. And then I would still recommend pursuing DNR, time-limited trials and no escalation, when appropriate because it begins to have  discussions that are very informative for the patients and their families about the seriousness  of the situation. In this paper we wanted to make the point that it is important that the wisdom  with which ECMO is used keep pace with advances in its use. And again from Thomas Byne, are intensivists prepared to address ethical questions related to this evolving technology?  Well the answer I think is that we are better prepared to do so as a team. Thank you very much. Good morning, my name is Katie Moynihan. I'm going to focus on the practicalities  of framing discussions between clinicians and families. These are my disclosures.  First I'll broadly describe the critical care clinician's role in decision making, then outline an approach to conversations during ECMO,  and finally discuss options for navigating disagreements.  Increasingly, the holy grail in medicine is to provide goal-concordant care. We hope that after  today's session the fog will be partially lifted in navigating shared decision making towards  goal-concordant care in ECMO, although weighing benefits and burdens is highly subjective and we acknowledge there are inherent challenges.  The critical care clinician's role in decision making is changing. The critical care clinician's role in decision making is changing. A spectrum exists.  At one extreme, paternalism involves unilateral clinician decisions and at the other is neutral provision of a menu of treatment options.  As Dan mentioned, shared decision making is the promoted model for serious illness communication  and involves a partnership. Early definitions describe clinicians assimilating medical facts,  prior experience and knowledge of the patient's health-related values to make a recommendation and persuading the patient on this approach.  Autonomy is generally the highest health principle for decision making  and unfortunately there is a concerning trend in medicine to adopt a more menu choice approach in the name of autonomy.  However, respecting autonomy does not abdicate clinicians' decision making responsibility nor prohibit provision of value-based recommendations.  Failure to do so is actually contrary to principles of shared decision making  as it fails to provide important contextual information and so precludes true informed consent and it places significant burden on surrogate decision makers  if they feel the responsibility lies exclusively with them.  And so serious illness conversation guides are emerging to aid shared decision making towards goal-concordant care.  Numerous benefits are described for patients, families and staff from setting clear expectations towards a common treatment goal, benefiting bereavement,  avoiding conflict and improving staff wellbeing.  The literature highlights value in early communication of risks and benefits,  identifying milestones that correlate with progress,  frequent updates balancing benefits with burden,  eliciting values and providing value-based recommendations. This is particularly relevant for ECMO. It's high risk, high reward, instituted emergently  and exerts significant psychological distress on surrogate decision makers.  ECMO affords time for relational value building but also may result in conflict.  Many parents recall first discussing the possibility of mortality only after their child failed to improve on ECMO and felt poorly prepared for decannulation.  Unfortunately, while imperative to guide clinicians on communication during ECMO is stressed in the literature, no practical approach exists.  I'm part of an interdisciplinary team of psychosocial, palliative care and critical care clinicians  who developed a structured conversation guide for ECMO that is currently under review. While paediatric focused, there is obvious applicability across all ages. Also, while  directed at patients post cannulation. As Wynne and Dan alluded to, pre-emptive discussions in patients with recurrent ICU admissions or with a slower declining trajectory are  equally important. Foundations lie in communication literature across other complex, life-threatening  conditions. Proposed conversations are for critical early time points during ECMO, relevant for all cannulation, and towards decannulation for alternate outcomes, including when end  of life is anticipated or possible. While this is framed as a day-by-day talks, flexibility has to be afforded for where the family is at and steps may need to be repeated.  The overarching approach defines ECMO as a temporary support device towards a specific goal or goals. Goals of care are elicited with families and surrogate decision makers  and how ECMO may or may not promote these goals are discussed throughout the run with medical recommendations for discontinuation if ECMO no longer helps to achieve that goal.  Here I'll outline our proposed approach and include example phrases. When confronted with bad news, families retain minimal content. So the day zero talk at ECMO initiation is  brief. First, disclosing the serious nature of needing this level of support. ECMO is reserved for the most severe cases. Without it, he would likely not survive. Unfortunately,  even with ECMO, many in his place don't survive. ECMO is described as a support device to achieve  goals that are defined with families and surrogate decision makers. For many, the goal is to  return the patient to a similar level of function and quality of life. ECMO allows time that is a bridge towards somewhere. Describing ECMO as a temporary support to achieve these  goals lays foundation for subsequent conversations if the goals can no longer be reasonably achieved  through ECMO. ECMO allows time to rest while we hope for recovery. Clinicians should align with the family and hope for the best while additional prognostic information is gathered.  We will continue to hope with you that he will be okay and are working towards that goal with you. The day one talk addresses two objectives. First, detailing risks, benefits,  burdens and the spectrum of outcomes. Then further eliciting goals for using ECMO. We  make decisions together, considering what's important to him and your family and our understanding  of disease. What are you hoping for? Prompting may be required. Some families value survival above all else. Many hope to get him back to enjoying the same kind of life as before.  At the moment, our hope to achieve our goal outweighs the burdens. Every day we will assess that balance. Second, we prepare families for the what ifs, such as a complication or  transplant no longer being an option. This provides anticipatory guidance towards decannulation  if the goals cannot be accomplished with ECMO. We worry as time progresses the chances of achieving the goals we hope for diminish. For some, the heart and lungs never recover.  If we are worried that we are not able to return him to enjoying the same kind of life as before, we will talk with you about discontinuing ECMO.  Throughout the ROM there are iterative conversations. Sharing worries creates an illness trajectory  narrative that helps families and surrogate decision makers simultaneously appreciate the medical challenges ahead while holding on to hope. What is your biggest concern right  now? I'm worried we haven't seen any signs of recovery so far. Our goals may be becoming further from our reach. Values are explored to ascertain what may be important in different  scenarios. Given this news, are there things you want to avoid?  The decannulation talk is for when further time on ECMO will not help us achieve our goals and end of life is possible or anticipated.  We are in a different place now. Despite the time and support it is clear that his body will not recover. More time will not help us. As sad as this is, it's now time to talk  about discontinuing the machine.  We advocate for direct recommendations that ECMO be discontinued. The anticipated outcome frames subsequent conversations. If survival is not expected, work collaboratively, giving  a defined period of time for goodbyes.  Based on how important it is for you to be together, I recommend taking a day to gather your extended family. After you have had the opportunity to say goodbye, we will discontinue  ECMO and that will be the natural end of his life. Some clinicians check in after such a recommendation is made to obtain assent. At the same time, non-dissent is acceptable.  If survival is not expected, then end of life planning and memory making should ensue with critical contingencies for unexpected surface failure.  We will prioritise comfort over other therapies. It doesn't make sense to do more invasive or painful procedures.  For patients in whom survival is possible, yet prolonged ECMO confers no benefit towards  the goals, so one-way decannulation is planned with ongoing support. And in addition to end of life planning, it is reasonable to set limits on escalation. Reaching such limits  may be described as signs that his body is failing despite support and the natural end of life is approaching.  Now we know it's not that simple. Conversations occur across different situations, values are elicited from different decision makers with varying perceptions and expectations  about current and future quality of life within and with families and also teams. Building consensus can be challenging. However, all professional opinions inform decision making,  even when conflicting.  We also must acknowledge how implicit biases influence our recommendations. Communication is a skill, requires training to learn and practice towards competency. Critical care  also has inherent time constraints with shift work and prognostic uncertainty means responsibility for providing recommendations can weigh heavily.  Because of these barriers or for other reasons, despite our best intentions, conflicts can  occur. In the same way that conscientious objection to brain death is emerging, as ECMO may preclude  circulatory death, many wonder if opposition to ECMO discontinuation is our next big challenge.  So how do we navigate disagreements occurring despite our high quality communication and negotiation?  One path is to describe ECMO as a potentially inappropriate therapy, defined as life prolonging  intervention with no reasonable expectation of sufficient improvement to survive outside  the acute care setting or neurological function to allow patients to receive treatment benefits.  A process based approach is recommended when an intervention is potentially inappropriate yet it is requested. This includes enlisting expert consultation, for example, ethics and  palliative care, second opinion, interdisciplinary hospital committee review and offering transfer.  When time pressure means it's not feasible to complete all these steps, while endeavouring to achieve as much procedural oversight as possible, clinicians can refuse to provide  the requested treatment if they appropriately answer these questions to illuminate moral blind spots. Ensuring they have a high degree of certainty it's outside accepted practice,  are willing to have the rationale publicly reviewed, understand the consequences from implementing the decision and assure that implicit biases are not entering into it.  When efforts to resolve conflicts fail, clinicians may find themselves in the court of extramural  appeal. How a court might consider a petition to allow or prohibit the intervention in dispute  will vary depending on the laws of different countries and states and how they're interpreted for that case. In rare situations where ECMO is physiologically futile, clinicians are  not obligated to provide interventions which simply cannot accomplish the intended physiologic  goal. In rare circumstances where perceived benefits of suffering remain substantial after exhaustive attempts to palliate symptoms with no treatment benefit except postponement of  death, some institutions and states have policies surrounding unilateral DNR and withdrawal orders. Clinicians should carefully present a well reasoned rationale in these settings.  Thank you so much for your time today. We would love to have a discussion now and are open to answering any questions.  Good morning everybody. Thanks to the program committee for allowing us to present today and to Wyn and Dan for joining me. I have to name how diverse our panel is including  adult and paediatric providers. Hopefully we'll have a rich discussion now and we're really excited to answer some of your questions today. Now whilst some of the questions are  coming in, I'm going to get the ball rolling and ask Dan and Wyn a specific question to offer their practical wisdom and if they've ever actually had a patient or surrogate decision  maker refuse discontinuation of ECMO.  Wyn, do you want to start or should I take that? I'm okay starting Dan. I have absolutely had that happen and I think refusals can come  in a variety of fashions. Sometimes a refusal is simply an emotional response and needs to be managed as such and just with support and a little bit of time and recognizing the  emotion that is there and then clearly sometimes a refusal is something that is more of an  adamant refusal and I guess a couple of illustrations of things I've seen handled in different ways.  I remember one case where a child did not recover cardiac function after surgery and it had been several days and the consensus of surgeons and cardiologists had decided  it was not likely to recover, said to a family, it's time to stop. The family answered with  no, no, you can't. We need more time and very compassionately the response was no one could ever be ready for something like this. We're stopping tomorrow. Gather your family and  supported them emotionally and the family did not object further once they understood that that was the medical decision. Another case that was perhaps more or less challenging  of a family who kept asking, you know, many providers had told this family it was probably time to stop. It had been weeks on ECMO and was not working and the family kept asking  every provider, are you 100% sure there's no chance? And almost every provider kept coming back with saying, well, I'm 99% sure and the family said, well, let's keep going  and that one lasted for a while. So supporting families through this can be very challenging.  I think you did a beautiful job, Katie, of talking about supporting the emotion and I think that's what it takes for the vast majority of them. And then when it is a more adamant  or entrenched objection, still working on developing that alignment and relationship can work, can help. Dan, sorry, I talked too long.  No, I mean, that's terrific and I agree that that really encapsulates sort of our experience  with it. You know, I'd say the one other aspect is jurisdictional differences in the approach  and I very much like, you know, in the right setting, as you said, compassionately said, the idea of assent, you know, we're going to stop, you know, just want to let you know.  And obviously, if they adamantly object, it might go in a different direction. I think it's a very important tool to have. In New York, where we practice, it's a little bit  more restrictive in terms of what we're allowed to do, but those are the kinds of things that  we would use to approach it. The other aspect is when the patient's awake and, you know, certainly in the awake adult patient who has capacity to make decisions, which we come  across most frequently, but not entirely in the bridge to transplant population, where it can become a bridge to nowhere if, for instance, there is something that then disqualifies  them from going on to transplant. And that can be a particularly difficult discussion of, you know, as you begin to talk about when you might want to stop, what is the day on  which you want to die is a very difficult conversation to have with somebody face-to-face. But I agree, as Katie talked about, it is really about, you know, supporting the patient  and the family through that, finding out what their values are, you know, and, you know, what are the goals before the end of life? And oftentimes, it is tying certain things  up, being able to say something to family or friends, you know, their last goodbyes, divulging a secret something, it is really amazing what can come up. But those are the  ways in which I think we need to support the patients. I think you are absolutely right.  I want to add to that, that those cases where the patients are awake, which happens sometimes  in paediatrics too, are the hardest for the staff as well. I have seen so much distress. Absolutely. And I think a few or a lot of us have mentioned the multidisciplinary team  within which we work in dealing with a lot of these patients. And certainly, the provision and anticipatory guidance that can occur when working with these patients who are awake,  using our psychosocial providers is particularly useful to help with, you know, doing things like legacy and memory building and things like that for these awake patients and just  taking the time to support them through this ridiculously challenging situation. So I think  that's a very, very difficult case. And there's been quite a number of questions through dealing  with awake patients. I think another concept which is coming up a lot in the questions  or in the chat section is about multidisciplinary teams and how individual institutions incorporate,  for example, palliative care and things like that in huddles. Wyn and Dan, do either of you  in your institutions have something like that entrenched as a structure?  I guess I'll start. We do. It's rather than a formula so that every patient is the same in that respect, it's tailored, and I think this is probably true in most centers, towards  the individual situation. Palliative care is a very common consult of ours, very important to our team, but there are many others. And in fact, oftentimes in these situations, the  people who can help us with decision making are people who have bonded the most with the patients. So as part of that, I mean, never, ever forget, you know, the role of nursing  and, you know, how close they become to the patients and families. Sometimes it's our social workers, sometimes it's the people who come in, you know, our environmental staff  come and clean the room, develop very close relationships with the family and can be helpful when we get to end of life discussions. So we don't have, you know, one approach in  different patients, but we'll pull in all of these different teams when it comes earlier than that final discussion, you know, along the way so that we're approaching it, I think,  as consistently as we can and trying to really decipher what the family's needs are.  From speaking of including palliative care and how we manage that, I know many institutions have triggers for palliative care consultations and sometimes, you know, a certain period  of time on ECMO or even being an ECMO patient is one of those. We do not have that. We don't  meet all of the ECMO patients because we actually do believe that many times the, you know, primary palliative care skills of the ICU team are truly what is needed and bringing  in a new team may or may not have added benefit depending on what's going on. Our palliative  care team does meet every patient being evaluated for heart or lung transplant. And so we meet  many of the ECMO patients and particularly many of the ones that may end up having prolonged courses while awaiting transplant. And so that involvement does happen early on. But  I think we leave it to the ICU team judgment for the majority of other patients as to whether adding new people at what time is useful.  Yeah, and I would just make one more plug, as I mentioned in my talk for the spiritual care team, that one of the things that I think many of us, myself included, sometimes mistake  is that it's for those patients and families who are religious. And that is not necessarily always true. And our spiritual care team, which is, you know, broadly construed, has  been incredibly helpful in patients who self-identify as atheist or non-denominational of, you know,  of some particular religion. And so involving them to the extent that we can, and really in that case, mostly to the extent that it's understood to be of value to the patients  and families, it can be incredibly helpful.  Yeah, the existential cost doesn't matter no matter what your religion, right? Yeah. Yeah. Dan, I know you mentioned in your talk when we were kind of discussing decannulation  and going through that, the sanction of non-escalation of therapy. I'm interested in you talking a little bit more about that.  Yeah, I think it is an option to always consider. As we would, in this way, I think treating  ECMO patients the same as all of our other patients who are moving towards the end of life is important. And, you know, the question with the ECMO is, you know, is there a viable  non-escalation? So if you have a patient, you know, on pressers and you're not going to escalate the pressers, you know, that's much more familiar to most of us than the  idea that we're not going to escalate the ECMO. Now, that could be not changing the configuration to adding another limb. And it's often simply not changing out a failing  part of the oxygen, whether it's the pump or failing part of the device, whether it's the pump or the oxygenator or anything else. And so that, again, you know, depending on  where you practice for us, it has to be in cooperation with whoever is the decision maker is the patient or the surrogates. But we will often, you know, approach that as a means  of acknowledging that we are getting towards the end of life. And of course, if you're going to limit treatment like that, the patient should be DNR. You know, even if they're  on VA ECMO and they're on enough support to provide eCPR, the notion of DNR in that setting is a good way for the family to come to grips with we're at the end of life. And  I think that, you know, we sort of package those things together. So DNR, no escalation of the ECMO circuit or other therapies at the same time is how we approach it.  Guys, I'm interested in, there's been a few questions in the chat about the resource limited setting in the current COVID-19 climate. And Dan is our adult provider here.  Has your decision making changed in that context because of the pandemic? Yeah, absolutely. And it's evolved since the beginning of the pandemic. And I think  one of the key things that Winston said at the beginning of her talk is, you know, you're  going to be disappointed if you expect me to give you a strict cutoff or something or anything. And I don't think you should be disappointed. I think it should be heartened  because we should all want that flexibility built into our decision making. We should  have principles by which we come to a decision, but then we should approach that on an individual  basis. So when it comes to crisis, the way I would frame it is that the indications for ECMO don't change. So whatever those indications were prior, whether that's, you know, fairly  well accepted across the field or it's your center's indications for a particular type of ECMO in a particular patient, that really shouldn't change. We should be using the same  evidence to approach it as we can. And if there's anything COVID-19 specific, then using that is incredibly important. But it's the contraindications that change and that are  flexible over time so that if you're in just a little bit of crisis, your hospital is under some strain, but you can provide essentially your normal services, well, then you'll use  your normal criteria. However, as that evolves and depending on what your resource limited in, you may have to change your criteria to be more restrictive. And, you know, being  more restrictive could be taking patients who don't have as many, at least in the adult population, comorbidities, who don't, you know, who might be younger, although, you  know, age, we should be very careful in talking about as a criterion in the adults, because there's a big difference between physiologic age and chronologic age. You know, a patient  who's 30 years old who has advanced diabetes with bilateral amputations of their lower extremities, CABG, you know, blindness on dialysis, and I've had several patients like  that in the recent past. And you can have a 90-year-old who's, you know, running races. And so thinking about age is, you know, an absolute cutoff can be very complicated. But  that cutoff might change. You might, because particularly in COVID-19, we know that age is a huge risk factor for mortality, both in the setting of ECMO and outside the setting  of ECMO. And so you might lower that age cutoff, or you might decide that you're not going  to take patients who are already have multiple organ failures, whereas you might take a chance  on a patient like that. And I think that as your resources get better, you should stretch them back again. And so it's really more of a conversation where this is thought of as  a dynamic phenomenon, you know, decided in real time as a team. I don't think these are at almost any center, really individual decisions. But as a team, really, it requires you to  have a good understanding of what your resources are at that time, and what they're going to be during the time that patient's going to be on ECMO. So if you know they're going to  have a run of several weeks, and you anticipate you're not going to have any staffing the next week, that should play into the kind of decisions that you're making. And then  I would think very broadly about, you know, whether you're taking just COVID-19 patients or you're also seeing your regular patients, and what the difference in survival might  be. If you know that in COVID-19, at least in the adults, the patients have longer run time and lower survival, well, you might be more inclined to take somebody without COVID-19,  all other things being equal, because they might have a better chance of survival if you have limited resources to use. And that could be a cardiogenic shock patient, it could  be an ARDS patient. It's less likely to be an eCPR patient since overall the survival is less, although the cardiogenic shock and eCPR patients will have shorter run time.  So, again, factoring all of that in to make what is ultimately a judgment decision is really important.  I was just going to add that just kind of just as Dan was saying that it also impacts whether it's an emergent or controlled situation can be one other factor going into that and  institutions may make different decisions about whether they offer ECMO, you know, but  not in the eCPR situation, for instance, if there is less chance of a good outcome and more risk of not being able to prepare staff for the precautions they need to take. And  I think that changes as we move through the pandemic and learn how to better protect ourselves  and it may also change as healthcare workers become vaccinated and, you know, we need the data to know to learn from that. So, and we need to be ready to adapt.  There's some interesting questions coming through when about informed consent and how we can actually provide informed consent when really the alternative is death for  these patients. And so I think that's a very interesting thing to think about in terms of the two potential timeframes that we'll be dealing with, which is emergent situations  where we just don't have the luxury of time and then others where we've got a little bit more time on our side to think through those kind of discussions.  Yeah. And you're right. That is the distinction. Sometimes we do have time if we're, you know,  talking with, say, a potential lung transplant recipient of are we going to use this as a bridge, but it's not an immediate decision. But in the Martha Curley study that you quoted,  you know, the parents who were asked about their decisions at the time when their child went on to ECMO, most of them in hindsight felt like there was not even any decision  to be made, that the team simply told them, this is what we need to do. This is what might  save your child. It's what we're going to do. And I think in the initiation point that, you know, that is one of the reasons I argue that the medical teams thought about who is  an appropriate candidate is a vital component of the decision because it is, you know, so hard for, you know, a family to completely wrap their head around all of this if it's  coming up very quickly. So informed consent is important, but almost instead of informed  consent, I think of it as managing expectations and, you know, informing as much as we possibly can, making the best medical decisions we can, informing the family. And if they are  objecting to things, it needs to be more of a discussion. But you're, you know, not going to say like, hey, we have to do this in five minutes, this thing you've never heard of,  and your child will die if we don't do it. Here, you tell us, you know, you're going to guide them through that. Did I answer the question, Katie?  You did. And at either of your institutions, is there an approach to, you know, kind of that kind of decision making early on? For example, when patients get admitted or something  like that, where you've got a system where this is a patient that we would put on ECMO, this is a patient we wouldn't put on ECMO at your institutions, is that kind of decision  made early on? Or is it still left to the individual provider at the bedside? We don't have a system for flagging, you know, ECMO candidate or not, although I have  certainly heard of places that have done that. We tend to start having the multi-specialty, multi-provider discussions, if it becomes apparent that there's a risk that this patient  might end up heading towards ECMO. And then we do have systems in place for trying to communicate if those discussions have happened through the medical record, but we do not  proactively have on every single patient in the ICU, for instance. Yeah, I think our approach certainly in the bridge to lung transplant patients is to often  think about that ahead of time. Sometimes when they're in intermediate care and definitely by the time they've reached the ICU, we have a good sense as a multidisciplinary team led  by the lung transplant docs about whether or not this patient would be a candidate as  a bridge to transplant. We do that occasionally with patients who come in with other conditions.  Particularly during COVID, we have had multiple discussions about patients. Would we consider ECMO either now or if the patient worsens, would we consider it later on? So not done  in every patient, always done as a team, but it is helpful for the ICU team to be able to have that knowledge and be able to work with the families on that.  Then in terms of the last question, I was also just thinking that if something is truly emergent, it's implied consent. If we think we're moving forward on things and something  has to happen right away, of course, call the family. But if you can't reach them, we know we've moved forward. And you can reach them exactly as Wynn was describing. You're  trying to have the most informed consent you can, but we've got to move forward. And unless they say, no, this is the time when we're going to back off of aggressive care, then  the answer is if we think that that's indicated, then we should move forward with implied consent.  Thanks, guys, for listening and for a really engaging session. I'm going to follow up on a number of the questions that remain in the chat that we haven't managed to get to today.  I think if I could just spend the last kind of 15, 20 seconds just thanking very much my co-presenters, Wynn and Dan. Wealth of knowledge. And it's been a really, really  interesting session. So thank you very much all for joining us. And as I mentioned, please add any questions and we'll do due diligence to answer them in the next couple of days.  Thanks, Kate.  Thank you.

Video Summary

In this congress session, clinicians discuss controversies surrounding the initiation and discontinuation of extracorporeal life support (ECLS), also known as ECMO. ECLS is a support device used in patients with severe respiratory or cardiac failure. The session begins with a discussion on ECLS candidacy, highlighting the history of ECLS and how candidacy has evolved over time. The speakers emphasize the importance of individualized decision-making based on patient factors and available resources. They also discuss the role of time-limited trials, in which the therapy is continued if the patient improves, but discontinued if the patient deteriorates. The session then focuses on discontinuation of ECLS, including the challenges in framing discussions with patients and families. It is important to provide clear guidance on prognosis and alternate treatment options, while respecting patient and family goals and values. The speakers stress the importance of a multidisciplinary approach in decision-making, including the involvement of palliative care, spiritual care, and other relevant specialists. The session concludes by discussing the options for navigating disagreements and conflicts that may arise in decision-making. Overall, the session highlights the need for shared decision-making, individualized care, and ongoing communication with patients and families.

Asset Subtitle

Ethics End of Life, Procedures, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Examine decision-making challenges surrounding initiation and discontinuation of extracorporeal life support (ECLS) in contemporary intensive care practice utilizing ECLS technology
Recognize current controversies and practice variability surrounding patient selection for initiation of ECLS and timing of ECLS discontinuation and compare and contrast issues across adult and pediatric settings
Construct an approach to ethical decision-making and apply communication strategies in framing conversations with patients and surrogate decision-makers in discontinuation of ECLS support

Getting on the Bridge: ECLS Candidacy
Wynne E. Morrison

Getting off the Bridge: Discontinuation of ECLS
Daniel Brodie

Navigating the Bridge: Approaching Decision-Making and Framing Discussions
Katie Moynihan

Meta Tag

Content Type Presentation

Knowledge Area Ethics End of Life

Knowledge Area Procedures

Knowledge Level Advanced

Learning Pathway Skills and Procedures

Membership Level Select

Tag Extracorporeal Membrane Oxygenation ECMO

Tag Communication

Year 2021

Keywords

ECLS

ECMO

candidacy

time-limited trials

discontinuation

patient factors

multidisciplinary approach

prognosis

alternate treatment options

shared decision-making

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