Hello, my name is Kara Egerstrand. For the next session, we're going to discuss some difficult considerations in ECMO. Due to the change to the virtual nature, we won't be able to have our interactive case-based discussion. However, we will discuss some other very difficult scenarios that arise when taking care of patients on ECMO, namely the ethical issues involving ECMO. I have no disclosure or conflicts of interest. So what is our quandary? Well, ECMO creates a whole new population of patients that may be awake, interactive, and yet completely reliant on mechanical, artificial life support. This brings up ethical challenges that arise, namely the idea when ECMO becomes a bridge to nowhere. This can occur with patients supported with ECMO who were cannulated with an intention of bridge to transplant and also bridge to recovery. Here's a challenging case to illustrate this exact scenario. In a patient who was cannulated with ECMO with the intention of bridging to transplant, a 40-year-old woman with underlying scleroderma and advanced ILD who is listed for lung transplantation. She was admitted with an ILD flare. You can see her X-ray in the background. And while in the ICU, she decompensated quickly. She developed severe hypoxemia, RV failure with a pH crisis, and a brief cardiac arrest, and was cannulated emergently with a VAV ECMO configuration to provide both cardiac and hemodynamic support. Once she stabilized, she was converted to an upper body veno-arterial ECMO configuration. Then she was managed in an awake, excavated, and active manner. She initially did quite well. She was eating, working with physical therapy, communicating with her family. However, after three weeks on ECMO support, a lung offer still had not come. She became progressively weak and deconditioned and had developed multiple MDR infections that were difficult to clear. She also developed progressive renal failure and was deactivated from the lung transplant list, determined no longer to be a candidate. And so now we run into the scenario where ECMO cannot be used as a bridge to recovery given her advanced ILD. It is no longer able to be used as a bridge to transplant, its original intention. And unfortunately, we don't have ECMO as a bridge to a long-term destination device such as a pulmonary assist device or an artificial lung. ECMO has effectively become what we would call a bridge to nowhere. And this is where we've reached the limitations of our device therapy. ECMO is no longer meeting its intended goals. So where do we go next and how do we proceed? Well, there are several routes. One, we would like to say it would be appropriate to say there's no escalation in ECMO support with discussions of limiting life support in general, withdrawing life support in an institution of a DNR order. However, this patient and her family wanted to continue aggressive care. She didn't understand why she couldn't just continue to live on ECMO. Palliative care was closely involved and their documentation, you can see, states, in discussing her current clinical circumstances, the patient began to tear up and expressed her desire to live longer on ECMO if possible. She feels strong and she has a desire to live. This is a really heartbreaking scenario and a difficult one as what do we do when a patient declines the withdrawal of ECMO? Could the device simply be removed against the patient's or family wishes? And this brings up these challenges of a bridge to nowhere. It can become an emotionally charged and very difficult scenario for both the patient and family, for the hospital staff, the ICU team, the hospital and the healthcare system as well. As we've all seen in the last two years, our ICU beds, our staffing, and ECMO certainly are all resource, can all be resource limited and are precious commodities. And what is the role of the medical team in this scenario? Well, we must respect patient autonomy and we cannot unilaterally withdraw ECMO support against a patient's or family wishes. We must allow for understanding of the medical condition and the expected outcome while providing honest and frank information regarding patient prognosis on ECMO and without the option of transplantation. We also must work very hard to identify the fears and concerns. And sometimes it might be surprising. In this particular case, one of the patient's biggest concerns was economic and that she wasn't sure how her husband would be able to cope with the finances of the households and she was the one who typically managed and organized these things. We also want to always stress palliation and comfort at the end of life and ensure that this will be a priority regardless of any other developments. Three weeks later, after multiple discussions with the patient, with the family, with the religious personnel, she was ultimately made DNR and ECMO support was withdrawn on a day that was amenable to both the patient and her family. This brings up the question of what is the right timing of end-of-life discussions. It can be quite hard and challenging in patients who are going for lung transplantation, who are fighting, fighting, fighting to get there, to also be entertaining the idea of a potential palliation or if things take a turn for the worse. When is the right time and what is the role of palliative care involvement? Should palliative care be consulted in all patients once they're on? Should they be involved prior to cannulation or potentially even before transplantation listing? So the patients and families have a better understanding of all the potential outcomes. And how is this reflected in the consent process for device therapy? Also, it brings in the question of what are the different considerations when it's a patient making the decisions, as in this case, versus the surrogate in the case of a patient who is unconscious or unable to interact with the ICUT themselves. In looking at the role of palliative care consultation, in 59 pediatric patients who were supported with ECMO, they all received a palliative care consult. What this team found was that palliative care required only low involvement in about 25% of cases, medium involvement in 50, and high involvement in 25%. What dictated the higher use of palliative care resources or requirements was prognostic uncertainty or medical complexity. In the medium involvement, patients had one or the other. In the high involvement cases, they had both prognostic uncertainty and medical complexity. And also, palliative care was crucial in coordination of care, in addition. Now, what about moving beyond bridge to transplantation, but bridge to recovery? This brings up unique situations and patients who may be particularly unprepared. For example, in a patient cannulated with ECMO for ARDS, all intention of bridging to recovery. What happens when the lungs don't recover and the patient is now stuck on ECMO? Well, potentially, some of these patients would have never been transplant candidates or transplant-eligible, period. Perhaps their BMI or other comorbidities would preclude transplantation. If they are possibly to be considered for transplantation after cannulation for an acute process, what exactly does that inform consent likely? How is an education that's typically done over months in an outpatient setting where patients learn about transplantation and what a post-transplant life entails? How is that performed in an ICU when a patient is already supported with maximal life support? And what is the right timing of all of this? How do we know when the lung is irrecoverable? Some patients have been transplanted after ARDS after a matter of weeks, where some have been supported with ECMO for over a year. There's really quite a wide range in practice with very little evidence to inform our decisions. In thinking about COVID-19 in particular, data from UNOS shows that from August 2020, when this first became tracked, to October 2021, 238 lung transplantations for COVID were performed in the United States. This was 10% of the current transplants going to post-COVID patients. So I'm sure that many of us have dealt with, at least peripherally, patients who have been transplanted in this exact scenario, and we likely will continue to deal with it as time goes on. So what about when ECMO as bridged to recovery turns into ECMO as BTT? Again, what really does count is informed consent in this scenario. That patient may feel like they truly have no other option, even if they have concerns about a post-transplant lifestyle. And how soon is too soon? Are these patients truly irrecoverable? We've seen over time and with the advent of ECMO and our ability to support patients longer that the lung has amazing regenerative properties. But there may be some patients in whom this is simply not possible, and when is the right time to pull the trigger? What's the risk-benefit of time and watchful waiting? ECMO as eCPR, extracorporeal CPR, also brings in other ethical challenges. We know that ECMO as eCPR can increase survival after cardiac arrest and also can increase neurologically intact survival. This is encouraging and has saved many lives, yet it doesn't always work out as planned, unfortunately. And it's not the easiest endeavor to undertake. Issues regarding ECMO and eCPR, while it's certainly more invasive than other types of CPR, it's much more resource-intensive and can only really be performed at experienced centers and has the capacity to prolong suffering when there's a low likelihood of survival. And how do we select patients for eCPR? As ECMO becomes more incorporated into our standard algorithms for heart failure, for ARDS, when does the idea of doing everything begin to include eCPR? Is it possible that this needs to start to become incorporated into advanced directives? Or what about in a patient undergoing surgery? And what considerations need to be taken ahead of time or conversations need to be had ahead of time if someone does receive ECMO as eCPR, yet neurologic function does not recover? This also brings up the interesting concept of what it means to be DNR, or benign resuscitate, while on venoarterial ECMO. It can be difficult for patients or for their families to grasp what that means. How can a patient be DNR when they're really receiving continual venoarterial ECMO support? Ideally, these are issues that are addressed before ECMO cannulation, though that's not always possible. But hopefully, informed consent can include frank discussions of the prognosis, potential complications, and expected results. A burgeoning use, and still very rarely used, direction of ECMO is using ECMO for organ transplant and recovery, or OPECMO, so organ preserving ECMO, using ECMO to preserve organs for transplantation with that intent. This has been used rarely, but increasing over the last 10 years or so. This has been used in the setting of ECMO used after brain death determination, or for donation after cardiac death, where the brain and often the heart are isolated from ECMO circulation, and the ECMO circulation can perfuse other organs in the body. After brain death, two scenarios can arise, one where the patient is already on ECMO and then develops brain death, the least ethically complicated of the two. And two, when a patient is cannulated after brain death declaration for the intent of really preserving and recovering organs, or with the potential for brain death, again, for the intention of organ recovery. These are quite ethically fraught scenarios without a lot of guidance and a lot of understanding of how best to proceed. But some issues that arise, cannulation after brain death determination, what are the concerns? Well, there's a concern regarding bodily integrity and post-mortem cultural processes that may not be possible. There's also potential for confusion for families, as ECMO is typically a lifesaving endeavor and used for lifesaving purposes. There could also be this perception of instrumentalizing death. And what about cannulation in a patient with possible brain death, who's not yet or not quite brain dead? Well, there could be certainly concerns here causing harm, for example, bleeding that could ultimately hasten the patient's death. There may be more difficult detection of progression to actual brain death, given the difficulties of determining brain death when supported with ECMO. And there's also a risk of futility if brain death never occurs or if the organs are not able to be utilized. Then what was this all for? And there's certainly the risk of patient harm, for example, with pain. Potential benefits, on the other hand, would be the recovery and transplantation of additional organs in human anomaly unstable patients who consent specifically for OP-ECMO organ donation. Use of ECMO as OP-ECMO has been reported scantily in the literature, and it's not entirely clear in the reports how the consent process was undertaken or when exactly ECMO was initiated, whether in the pre or brain death scenarios. Finally, the last issue to bring up regarding ethics in ECMO is the idea of health equity and access. We can see that as ECMO use and ECMO centers have grown globally, there's not been an equal distribution of that growth worldwide. Most of the growth in ECMO centers and ECMO cases has been in North America and Europe. And I think we've certainly seen with the COVID pandemic that even within countries or within regions, there is not equitable access to advanced resources like ECMO, let alone on the global level. So when thinking about guidance for ethical considerations in ECMO access, what can be helpful? Well, it can be helpful to have predetermined consensus criteria for selection of ECMO candidates, be it at a hospital level, a regional level, potentially a national level, as some countries have done during H1N1 epidemic and also during COVID-19. Predetermined consensus regarding when to ration ECMO, if indicated, what it means, and how to best share ECMO between centers and direct resources where they're most urgently needed at the time they're needed, particularly on a local or regional level. Also brings up the idea of invoking distributive justice in circumstances where rationing precludes the ability to care for each individual patient optimally. Things that can be helpful include seeking opinions from hospital ethics or medical legal communities in the societal level or also in the country where the person in the center is for guidance as well in these ethically challenging scenarios. In summary, all these ethical issues involving the care of ECMO patients really bring up a lot more questions and answers, but they are really important considerations that as ICU practitioners, we really need to consider. As ECMO becomes more incorporated into our standard algorithms for advanced respiratory and cardiac failure, as well as eCPR cardiac arrest, these are certainly issues that are going to become much more commonly seen and require thoughtful consideration. So regarding advancements in ECMO technology with these new ethical challenges, they span from bridge-to-transplant, bridge-to-recovery, eCPR, organ transplantation, for OP-ECMO, and also the health equity and access avenues. Regardless, it's always helpful to have an approach on these difficult discussions or these complicated discussions with an open and frank approach with communicating with the patients and families, especially regarding the prognosis, the limitations of device therapy, and what the expected results may be. I hope you've enjoyed this session. Thank you very much for your time.

ECMO

bridge to nowhere

end-of-life discussions

palliative care

health equity