A previously healthy 45-year-old man is brought into the emergency department with chest pain and arrests immediately upon arrival. You begin advanced cardiovascular life support (ACLS), but after 10 minutes, he remains in cardiac arrest. You remember that extracorporeal membrane oxygenation (ECMO) has just become available at your hospital. Should you consider it for this patient?

ECMO—where oxygen loading of red blood cells and mechanical perfusion with oxygen loading are facilitated outside the body with a portable pump and circuitry hooked up through large vessels—has been used for more than 40 years to provide cardiac and respiratory support to patients who have potentially reversible causes of respiratory/cardiac failure. What began as a temporizing measure for meconium aspiration in neonates has gradually expanded to adult populations. Since 2015, the American Heart Association guidelines have cautiously included ECMO as a resuscitative option.1 The guidelines refer to two options: ECMO used in the emergency medicine setting is extracorporeal life support (ECLS), while ECMO used in the arresting patient is extracorporeal cardiopulmonary resuscitation (ECPR).

Placing an ECMO link in the chain of survival has shown promise for improving outcomes in refractory scenarios with previously healthy candidates. If you consider the use of ECMO, however, you need to be aware of the clinical and ethical considerations of doing so.

The Right Patient

Good ethics is based on good science, and there’s a great need for continued research to identify the best candidates for ECMO in the emergency department since current evidence is from observational studies only. Absent high-quality studies, data from ECMO registries and observational studies support a general short list for clinical consideration. Generally, patients who are eligible:

• Are 18 to 70 years old;
• Have a witnessed arrest;
• Have ventricular fibrillation or ventricular tachycardia as their initial rhythm;
• Have a presumed cardiac cause; and
• Received high-quality CPR delivered with minimal interruptions.

Patients with known cognitive impairment, evidence of multi-organ dysfunction, irreversible causes, do not attempt resuscitation (DNAR/I) status, or prolonged CPR/EMS transport haven’t been shown to benefit from ECLS/ECPR as a temporizing approach and should be considered ineligible.1–5

The decision to proceed with ECMO in the emergency department must be made quickly and with careful determination of how patients will benefit. ECMO should be considered a bridge to recovery (from a specific illness or organ damage), transplant, or other definitive care such as a left ventricular assist device (LVAD). If achieving a definitive recovery point is unlikely, ECMO shouldn’t be used. In these cases, ECMO is not a good use of resources, particularly if the necessary specialists or recovery options aren’t available locally and the patient must be transferred while on ECMO. Additionally, it has the very real potential of prolonging dying at the high cost of patient and family suffering.
Patients considered for ECMO are likely to be critically ill and lack decision-making capacity. When this happens, clinicians may ethically provide care with emergency consent under emergency conditions. Although it isn’t clear that ECMO ought to fall into the category of care provided under emergency consent, Riggs et al argue that ECPR in these cases may be acceptable given that the alternative is to withhold it from those who might benefit and may have consented to the treatment.

Bridge to Nowhere

Because it isn’t a definitive treatment, ECMO has the awful potential to commit a patient and family to a “bridge to nowhere,” an unthinkable scenario in which the patient is alive and functioning but confined to continued treatment in an ICU with no hope for ECMO discontinuation, transition to a definitive therapy, or discharge home. Decisions to discontinue care will be difficult because there isn’t a clearly established failure point such as cessation of cardiac activity; discontinuation ultimately may need to be determined by gradual multi-organ failure.

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

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

Budgetary Concerns

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

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

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

When considering the addition of ECLS to the emergency care available at a hospital, clinicians and administrators need to be mindful of costs, in particular the opportunity costs of developing an ECPR program in lieu of other initiatives that could improve the quality of resuscitative emergency care. Human resource requirements, including staffing, emergency response teams, and ongoing education, are significant.

ECMO and ECPR shouldn’t require a radical revamping of established ethical principles or best practices. However, ethical considerations in ECMO application should be considered proactively, keeping pace with resuscitative science. The resource intensity of ECMO care, the complexity of bridge-to-nowhere cases, and the uncertain role of ECMO in end-of-life conversations should serve as ethical limits to unconstrained growth of this technology, making sure the tail of technology isn’t wagging the dog of ethical practice.

Dr. Allen is director of healthcare ethics, Billings Clinic, Billings, Montana; and adjunct assistant professor of Medicine and Medical Ethics, Baylor College of Medicine, Houston, Texas.

Dr. Jesus is an attending physician, Augusta Medical Center, Fishersville, Virginia.

Dr. Knowles is director of leadership and advocacy for Integrative Emergency Services; and core faculty at John Peter Smith Health Network, Fort Worth, Texas.

Dr. Larkin is a professor at the University of Auckland/New York University.

Dr. Schears transitioned from the Mayo Clinic, is currently studying social justice and micro-economics at the Heller School in the inaugural year of the executive MBA program for physicians at Brandeis University.

References

1. Brooks SC, Anderson ML, Bruder E, et al. Part 6: alternative techniques and ancillary devices for cardiopulmonary resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl2):S436-S443.
2. Johnson NJ, Acker M, Hsu CH, et al. Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. Resuscitation. 2014;85(11):1527-1532.

3. Bellezzo JM, Shinar Z, David DP, et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitation. Resuscitation. 2012;83(3):966-970.
4. Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation. 2014;85(6):762-768.
5. Maekawa K, Tanno K, Hase M, et al. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med. 2013;41(5):1186–1196.
6. Avalli L, Maggioni E, Formica F, et al. Favourable survival of in-hospital compared to out-of-hospital refractory cardiac arrest patients treated with extracorporeal membrane oxygenation: an Italian tertiary care centre experience. Resuscitation. 2012;83(5):579-583.

7. Riggs KR, Becker LB, Sugarman J. Ethics in the use of extracorporeal cardiopulmonary resuscitation in adults. Resuscitation. 2015;91:73-75.

8. Ramanathan K, Cove ME, Caleb MG, et al. Ethical dilemmas of adult ECMO: emerging conceptual challenges. J Cardiothorac Vasc Anesth. 2015;29(1):229-233.

9. American College of Emergency Physicians. Code of ethics for emergency physicians. Ann Emerg Med. 2008;52(5):581-590.