ECMO between indication and futility

Introduction

The discussions about feasible and useful measures at the limits of life represent a central field of medical ethical debate. This is usually about the question of when a life-prolonging treatment clearly has no more benefit and the best possible palliative therapy alone should take precedence. However, determining this limit is anything but trivial. Extracorporeal membrane oxygenation (ECMO) is one of the newest life-prolonging intensive care procedures for very seriously ill patients. The ECMO allows stabilizing the patient for a certain time in the intensive care unit when lung and / or heart function is very poor or fails. What previously seemed to be a "futility" situation is now a potential indication for an ECMO. Some patients are for weeks on the ECMO, partly aware, probably with very low quality of life, nevertheless many die. The study examines norms, values, and behavioral intentions of occupational groups entrusted with ECMO (intensive care specialists, cardiothoracic surgeons, cardiologists, and perfusionists) regarding the criteria for (not) treating a patient with ECMO or stopping ECMO and converting to a palliative therapy. The study is carried out as part of a web-based factorial survey (vignette analysis). From the empirical findings, ethical implications and recommendations for daily clinical practice are derived.

Keywords

ECMO, Medical futility, Factorial survey, Decision-Making, Guidelines

Management

Cooperation

Charité – Universitätsmedizin Berlin – Institute of Medical Sociology and Rehabilitation Science, Germany

Funding

SNF, Personen- und Projektförderung

Project duration

2017 - 2019

Approach/methodology

The project starts with the conduction of two systematic reviews. One systematic review about clinical outcomes about ECMO, the other about guideline recommendations regarding (contra-) indications for ECMO. Based on the findings of these reviews a factorial survey will be designed. In factorial surveys the respondents are confronted with hypothetical situations, so-called vignettes. In these vignettes factors that are of interest are systematically varied in their levels. The study will be conducted among physicians that are involved in decision-making regarding ECMO.

Aims

The aim of this study is 1) to evaluate the relative influence of different factors that lead to decisions to initiate ECMO and which factors influence decisions to change the goal of care to palliation. 2) Consistencies among guideline recommendations regarding ECMO will be explored.