From Bridge to Destination? Ethical Considerations Related to Withdrawal of ECMO Support over the Objections of Capacitated Patients

Abstract

Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned.

Keywords:

• Decision-making
• end of life issues
• futility
• moral theory
• professional ethics

This article is referred to by:

Ethical Issues in the Transition to ECMO as a Destination Therapy

ECMO: What Would a Deliberative Public Judge?

Ethical Withdrawal of ECMO Support Over the Objections of Competent Patients

“Sorry, but the Ethicist Said Your Life Isn’t Actually Worth Living”: Misunderstanding Ethics and the Role of the Ethics Consultant

Bridge or Destination: Ethical Complexity, Emotional Unrest

Why Deny ECMO-DT to the Incapacitated?

Unilateral ECMO Withdrawal and the Argument From Distributive Justice

Battle of the Bridge: Ethical Considerations Related to Withdrawal of ECMO Support for Pediatric Patients over Family Objections

Fairly Distributing the Distributive Justice Argument Permits Stopping ECMO

The ECMO Bridge and 5 Paths

Can the Extraordinary Become Ordinary? Re-Examining the Ethics of ECMO-DT

When the Bridge Crumbles: Balancing ECMO-DT With Transplant Program Needs

The Divergence of Technical and Human Teleology

When Critically Ill Patients with Decision Making Capacity and No Further Therapeutic Options Request Indefinite Life Support

The Moral Relevance of ECMO Bridge Maintenance

Withdrawal of ECMO Support over the Objections of a Capacitated Patient can be Appropriate

The Human and Humanity that Differentiate Withholding from Withdrawing Life-Sustaining Therapy: An ECMO Bridge to Nowhere

Personalizing Care and Communication at the Limits of Technology

A Bridge to Nowhere

ACKNOWLEDGMENTS

We would like to thank our colleagues at the Center for Medical Ethics and Health Policy with whom we spent many hours discussing ethical issues related to ECMO support. In particular, we would like to thank Savitri Fedson, Claire Horner, and Adam Peña for sharing their insights and comments. We would also like to thank the anonymous reviewers whose thoughtful comments and recommendations greatly improved this article.

DISCLOSURE STATEMENT

None of the authors have conflicts of interest to disclose.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.