Perspective
Withdrawing extra corporeal membrane oxygenation (ECMO) against a family's wishes: Three permissible scenarios

https://doi.org/10.1016/j.healun.2023.03.014Get rights and content

The ethical permissibility of unilaterally withdrawing life-sustaining technologies has been a perennial topic in transplant and critical care medicine, often focusing on CPR and mechanical ventilation. The permissibility of unilateral withdrawal of extracorporeal membrane oxygenation (ECMO) has been discussed sparingly. When addressed, authors have appealed to professional authority rather than substantive ethical analysis. In this Perspective, we argue that there are at least three (3) scenarios wherein healthcare teams would be justified in unilaterally withdrawing ECMO, despite the objections of the patient's legal representative. The ethical considerations that provide the groundwork for these scenarios are, primarily: equity, integrity, and the moral equivalence between withholding and withdrawing medical technologies. First, we place equity in the context of crisis standards of medicine. After this, we discuss professional integrity as it relates to the innovative usage of medical technologies. Finally, we discuss the ethical consensus known at the “equivalence thesis.” Each of these considerations include a scenario and justification for unilateral withdrawal. We also provide three (3) recommendations that aim at preventing these challenges at their outset. Our conclusions and recommendations are not meant to be blunt arguments that ECMO teams wield whenever disagreement about the propriety of continued ECMO support arises. Instead, the onus will be on individual ECMO programs to evaluate these arguments and decide if they represent sensible, correct, and implementable starting points for clinical practice guidelines or policies.

Section snippets

Crisis medicine

The first argument for unilateral withdrawal of ECMO is most intuitive: when institutions implement crisis standards of medicine. Crisis standards require a shift in focus from providing a physiologically beneficial intervention from single patient to another patient, based on the perceived needs of the larger group.1, 2, 3 When crisis standards are in place, unilaterally withdrawing any medical intervention, including ECMO, can be ethically permissible.4, 5, 6, 7 Institutions should have

Conclusion

We have provided 3 scenarios where it is ethically permissible to unilaterally withdraw ECMO. Our arguments, while novel in their setting and specificity, apply established consensus positions to the specifics of withdrawing ECMO. We hope that ECMO programs will evaluate these arguments and reflect on their applicability. Without a programmatic approach, discrete team members may be willing withdraw ECMO when others may not, increasing the likelihood of variation, unfair access, and low-quality

Author contributions

T.M.B.: Conceptualized the manuscript, drafted the manuscript, edited the manuscript; A.Z.: Participated in conceptualizing the manuscript, edited the manuscript.

Disclosure statement

The authors have no conflicts of interest to disclose.

Thanks to Dr Divina Tuazon, Dr Erik Eddie Suarez, and Dr Howard Huang for initial conversation about this project.

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