Early, routine use of ethics consults is helpful if extracorporeal membrane oxygenation (ECMO) is considered for a patient, according to a recent study.1

Researchers analyzed 20 ethically complex cases from 2018 and 2019, identifying four key ethical domains: Limits of prognostication, treatment burden, system-level concerns, and the intervention becoming a “bridge to nowhere.”

“We undertook this study after leadership in critical care observed heightened moral distress among the care team with increased use of ECMO,” reports M. Jeanne Wirpsa, MA, BCC, HEC-C, a clinical ethicist and research chaplain for spiritual care and education at Northwestern Memorial Hospital in Chicago.

At that time, ECMO was an emerging advanced medical technology for adults. The hospital’s ECMO program had just started. “Ethics had been consulted on a couple of challenging cases, but only when conflict between the family and clinical teams had reached an intractable stage,” Wirpsa reports.

The department decided to initiate a protocol for early, automatic ethics consultation for every patient placed on ECMO. “This presented an opportunity to fill a gap in the research literature,” Wirpsa says.

Thoracic surgery, lung transplant, cardiology, critical care anesthesiology, and nursing all were involved. The researchers were aware that caring for patients with limb ischemia, dyspnea, and other side effects of prolonged ECMO was challenging for the teams.

“But we underestimated the degree of distress experienced, especially by bedside nurses. It was enough to make them question their vocational path in some cases,” Wirpsa says.

The researchers also knew there were uncertain indicators for initiating ECMO, but failed to recognize the moral weight of serving as the physician in charge of making that decision. “Our involvement facilitated a deeper appreciation of the unique challenges faced by each discipline,” Wirpsa says.

Managing the expectations of family decision-makers was particularly challenging. “Patients come to our institution because we offer advanced medical interventions not available elsewhere,” Wirpsa notes.

When a patient is placed on ECMO, usually emergently, families have begun to face the gravity of the situation. Suddenly, ECMO offers new hope. Even though the primary team explains ECMO will be a time-limited trial and a bridge to recovery, transplant, or device, many families remained focused only on the possibility of hope. The many services involved further complicated the issue. “Ethics initiated regular care conferences among the various treating teams and with family decision-makers to reduce mixed messages,” Wirpsa says.

By the end of the study, researchers had a much better sense of which patients and families would benefit most from ethics involvement. “The evidence, however, is not as definitive nor robust as we hoped,” says Wirpsa, adding that more research is needed to measure the impact of ethics consultation on ECMO patients.

“There are generally two approaches to ethics consults for ECMO or potential ECMO patients. At some hospitals, ethics consults are reserved only for ECMO patients if a specific ethical issue is identified,” says Andrew Courtwright, MD, PhD, external faculty scientist in the Yvonne L. Munn Center for Nursing Research at Massachusetts General Hospital. “Based on our institutional experience, this is typically when there is disagreement between healthcare surrogates and medical teams about whether it is appropriate to continue ECMO in a patient with a perceived poor prognosis.”

In some cases, surrogates want to continue ECMO, but the medical team disagrees. In other cases, surrogates want ECMO discontinued, but the medical team believes it is premature because the patient could recover. “Ethics consultants in these cases play a relatively ‘standard’ role in terms of identifying stakeholders, discussing values, and mediating conflict,” says Courtwright, an assistant professor of clinical medicine at University of Pennsylvania’s Perelman School of Medicine.

An alternative model is to engage in routine ethics consultation for all patients on ECMO, even if a specific ethical issue has not been identified. “The advantage of this approach is that ethics consultants are exposed to a range of outcomes for ECMO patients, not just circumstances in which there is significant disagreement about continuing ECMO therapy,” Courtwright says.

This gives ethicists the chance to find problems that have not become apparent. One study revealed consultants described an ethical issue in about one-fourth of cases when consults were conducted routinely for all ECMO patients.2 In an “as-needed” ethics consult model, it is possible clinicians eventually may have requested an ethics consult.

“In our experience, however, early ethics involvement can help mitigate some of the moral distress associated with the care of critically ill patients on ECMO,” says Courtwright, the study’s lead author. This is particularly apparent for patients with unclear prognosis and significant treatment burdens.

The drawback of a routine ethics consult model is the amount of time and resources necessary to staff such a service. It is especially challenging for hospitals with many ECMO cases. If ethics consults are going to be conducted for all ECMO patients, ethics “should be prepared for a step-wise rollout in volume,” Courtwright suggests.

After Massachusetts General Hospital started a routine ECMO ethics consult program, it took almost a year for the ethics service to build the capacity to see all ECMO patients within 48 hours. It was necessary to increase the number of full-time ethicists, develop interdisciplinary collaborations, and create a culture in which ethics always was consulted early.

“Ethics committees considering this approach should request financial and/or administrative support from their institution before embarking on this commitment,” Courtwright offers.

REFERENCES

  1. Wirpsa MJ, Carabini LM, Neely KJ, et al. Mitigating ethical conflict and moral distress in the care of patients on ECMO: Impact of an automatic ethics consultation protocol. J Med Ethics 2021 Jan 13;medethics-2020-106881. doi: 10.1136/medethics-2020-106881. [Online ahead of print].
  2. Courtwright AM, Robinson EM, Feins K, et al. Ethics committee consultation and extracorporeal membrane oxygenation. Ann Am Thorac Soc 2016;13:1553-1558.