Hello, everyone. Thank you so much for this opportunity to speak to you all. This is a topic that's very close to my heart and certainly something that us as anesthesiologists need to think more about. I don't have any disclosures except to say that I'm not a doctorate in ethicist. I'm a clinician who wants to find ways to address these ethical dilemmas. So we'll talk a little bit about some of the basic principle of ethics, and then we'll dwell a bit more into specific ethical challenges that we all come across with patients on ECMO. To have some common language to speak about these issues, we should think about the four pillars of medical ethics, which is beneficence, we must act to benefit the patients. Non-maleficence, we must not harm the patient. Autonomy, we should do everything to make sure the patient's as informed about his care. And then justice, where we have to have fair, equitable, appropriate treatment of patients. As you can already imagine, these are pillars that often come in trouble when you're dealing with ECMO. We have to realize that ECMO is increasing. There's about 200,000 cases that's recorded in ELSA registry. COVID pandemic was an extreme time of ECMO use. There are also now more ways that patients can be bridged out of ECMO. The number of heart transplants are increasing, ODCD and all those things. There's lower mortality and morbidity on LVAD patients. So it is more and more likely taught to be a better bridge option. But we have to remember that mortality remains high, especially in things like ECPR. ELSA registry says about 30% survival, but based on your institutional guidelines and patient population, that can be vastly lower. Anytime we're choosing a treatment, we really want this kind of scale where benefits far outweigh the risk. And the common benefits of ECMO we all talk about is survival. What that survival means, unclear sometimes. Bridge to recovery, transplant, the pot might be able to speak, make their own decisions. There is obviously risks of suffering and all the complications, a lot to do with bleeding, neuro injury, clotting. Patients on ECMO need constant invasive procedures. They are confined to an ICU unit and the dreaded bridge to nowhere. And I can't stress this enough, the extensive resource utilization. The scale sometimes at best looks equivocal and sometimes even on the other side. So with that in our mind, let's look at some common ECMO scenarios. This could be a patient that shows up to any ECMO center, a 75-year-old, pre-presents to ED with witnessed V-fib cardiac arrest and you get a call from the ED that they've been doing CPR for 60 minutes and would like to consider the patient for ECPR. In those settings, I think it's always helpful to kind of think through the pillars of medical ethics. Beneficence, we can say that there's possible survival, so we should do it. Non-maleficence, I would put a check mark or a cubical sign because it's unable to quantify. We're being called into this situation where we don't know about the medical history of the patient. We don't know how good the CPR has been done. We don't actually even know the exact time that this has been going. We're often given well-rounded numbers that can't be real. And then autonomy comes into question. Even to do arterial line, we get consents for patients, but now we're about to put a very invasive device into the patient, but we do not have time to consent them, most often not even their family. And it's not like ECPR discussion is part of a regular standard care. There's also extensive utilization, and we'll dwell a little bit more into that. So we have to keep in mind that ECPR is not something that a patient is able to choose for themselves. The patient is incapacitated, the burden of decision really goes on the proxy who is in this emotional distress time, and you're asking them that there could be a device that could help, they'll always say yes. Or if both of those things are missing, then the clinical team, and it's emotionally charged situation, and you're limited in time, you don't have time to consult ethics or the expert in that moment to make this decision for you. And if you're trying to explain it to somebody, it's a very complex technology, limited evidence, and it's definitely not standard of care. There's challenges to justice that we have to be very much aware of. We have to use an ICU room, we have to use a multidisciplinary team, the nursing, the APPs, everybody. These patients are not patients who you put on ECMO and then they're having a routine course through ICU. You're gonna have an extreme amount of team fatigue and burnout. These are the patients who two in the morning are gonna bleed, GI bleed, infections, sepsis, all of those things that are gonna require your team to be constantly on high cost to the system. And then we have times where of high need like COVID pandemic, and then how do you justify putting patients on ECMO while we were in New York City, Manhattan, during the peak of COVID, we had about 500, 600 people in ICUs, how do you justify putting patients on ECMO and taking away resources? So we'll go a bit more in detail of what we have done. We've tried to do it a three way, three things that we've tried to do to help this. We have a multidisciplinary team, so at no point other than post-cardiotomy ECMO can a big decision be made to put somebody on ECMO without agreement of anesthesia, critical care, heart failure, cardiac surgery, and in terms of VV ECMO, pulmonary. And that we also have ethics and palliative care councils that we have helped gain experience in these settings that can be called not so much in ECPR, but perhaps after. And we have really helped build institutional guidelines that we got buy-in from all three participants in ECPR, which is heart failure, cardiac surgery, and intensivist to help kind of allocate the resources to a population where risks might be outweighed by benefits. A lot of that came from, we were able to get this buy-in because our first two years our ECPR survival was 100% mortality. So at that point, we knew this wasn't working. Everybody had moral distress, fatigue, burnout. So that definitely helped. And then we helped develop a stage pandemic resource allocation pathway. So a multidisciplinary team gets any time patient needs ECMO and cardiology or pulmonary switch between VA versus VV, but cardiac critical care, in our cases are all anesthesia critical care intensivist and cardiac surgery is involved in every ECMO council. And since we have a team that has a lot of experience, we have a lot of collegiality. We do depend on each other. There is support within the team for each other. And you don't feel like you're trying to, it's not as confrontational. We also on the periphery have ethics and palliative care. We've built, we invite ethics for all our M&Ms and talks and to help work through conflict situations and for palliative care, any patient who gets put on ECMO, palliative care is consulted right away, not only just support for patient, but the family and the staff as well. And they come talk to us and these patients and these situations are very difficult. So it's important to have support. And as I was talking about, we are looking at the limited data there is an institutional expertise. We built activation pathways for ECPR as well as protocols. Overall, the protocols have some age cutoffs, some cutoffs for the kind of arrest. We only do VTV-Fib and then it's often very difficult to know a medical history of a patient in this situation for ECPR. But what we tend to use are metabolic markers of the efficacy of CPR, where we do want patients who have lactates are less than 18, pH is less than seven and so forth. But the key was to have a group consensus on a set of protocol that can reduce some of the moral distress, whether we all have to come into in this situations. We also went further and developed similar guidelines that we have buying from all the teams. We are situated next to a quaternary cancer center and we were getting quite a lot of consoles on patients who are failing quaternary fourth, fifth stage chemotherapy for possible ECMO. ECMO is not a cure. As you know, it's a support. So we were able to sit down with our oncology colleague and make oncological guidelines to guide our ECMO console. Same thing for hypothermic arrest. And that's probably our newest one. New York City doesn't get usually that cold till this past week where it's really cold. So it might be something that we come across. And then we learned, and this was published in ASIO, but we very much have a similar system that we developed during COVID where as we, our ICU capacity gets more and more taken over by a pandemic like situation. We have a tiered system where if we do have a crisis like COVID, we don't do, we don't offer ECMO because as it would be taking away resources. But as we get the pandemic more under control and had ICU nursing, perfusion, intensivist, all resources available, we slowly come down and make it more and more ECMO available for patients. So really our goal has been to reduce ethical distress by engaging multidisciplinary team, engaging ethics and palliative care consoles for the team, standardize some institutional guidelines, but get buy-in from this multidisciplinary team that we built and then have some high volume contingencies. The other case we'll discuss is, this was a case that came as we were coming around from COVID, this patient was a 34-year-old guy, had interstitial lung disease and got a, was already on a lung transplant list and had influenza pneumonia that pushed him over. We put him on ECMO. At that point, you know, if we look at from our ethical perspective, everything aligned. You know, this patient, young guy will, he already was a candidate for transplant. He was intubated so we were able to discuss with his proxy, but it aligned with his own intentions to get lung transplant. And then justice, you know, this guy is already on the transplants list and so we should help. However, you know, as best laid plans fall apart, this patient actually remained on ECMO for several months and kept having complications on complications. As you can imagine, that happens on ECMO patients which mean GI bleeds, bacterial infections. Eventually he developed a persistent fungal infection where it became no longer a candidate for lung transplant. So we got all our teams together, had a conversation with the patient about that since the ECMO was a bridge to transplant and transplant is no longer option, what could, how, what would be his decision? And he wanted to continue support and to spend time with his family. He didn't mind that he was in locked up in the ICU and undergoing all this. And at that point, this is a bridge to nowhere scenario where it often becomes a big conflict between the team caring for the patient and the patient themselves. Autonomy versus justice, as we would say, that patient, obviously the benefit is that the patient's awake and alive on ECMO, but you know, non-maleficence, I don't know how much, you know, what is survival versus suffering. The patient's alive, but he's locked up in the ICU, bound to his bed, only can move with five folks helping him move with the ECMO machine, has to constantly go under invasive procedures. But, and it's extreme utilization of resources for one patient. I mean, there was extreme staff burnout at this point, nurses, APPs, all kinds of surgery departments, all kinds of IR procedures. At some point people were saying, what are we doing for? So in those situations, I think one of the things that helps us as a shared decision-making model, which we use where we try not to make this confrontational and certainly try to change the question. And within that talk, we try to, clinicians get together and bring to the patient, they try to make sure we assess their understanding of the situation. We give them treatment option, risk benefits, while ask patient to tell us their values, their goals, their beliefs, whether it's religious beliefs, whether they have a goal, what do they want out of it? And in this meeting, we learned that the patient really was just happy that he can talk to the family, spend time with his family. But one thing he definitely did not want to do is undergo more painful, painful invasive procedures. So we together decided that if it comes to a point where he needs another painful procedure, he would readdress his decision to stay on ECMO. And that happened to him in a few weeks, his ECMO cannula actually cracked, and he was told that now he would need to replace the cannula and he opted to withdraw from ECMO and then passed away peacefully. So, there are no quick answers in ethics, there are no quick resolutions, but something that we all have to, as this new technology becomes more and more common, I think us as anesthesiologists and intensivists can play a key role in bringing teams together. I think that's where we can really excel and have a voice at an institutional level, help build these guidelines, speak for our patients as well as our team, and help bring more care, the right care to the right patient. Thank you.

ECMO

medical ethics

patient autonomy

multidisciplinary approach

COVID-19 pandemic