Venoarterial extracorporeal membrane oxygenation (VA-ECMO) should be provided to all individuals in emergency situations, according to a commentary piece recently published in the AMA Journal of Ethics. VA-ECMO should be continued until its burdens outweigh its benefits, and in cases of terminal VA-ECMO discontinuation, state laws should be followed.
This case study involved a 42-year-old man, without surrogate or advance directive, who was brought to an emergency department with refractory ventricular tachycardia. After various resuscitation attempts, the patient was put on VA-ECMO and moved to the cardiac intensive care unit. The doctor, who had little information on the patient, decided he was not eligible for left ventricular assist device implantation or a heart transplant and that chances of recovery were marginal. This created ethical questions, given that VA-ECMO is high-risk, costly, and complex to administer.
The study’s authors remarked that assessing the appropriateness of VA-ECMO should be comparable to that of other life-sustaining measures, in that it should be started when its reasonable potential benefits are greater than its potential burdens. It should not be refused to patients who are unable to make decisions. Decision making over time should be guided by new information and by the ethical value of benefits vs burdens. In addition, clinical ethics consultations and palliative care can guide decision making regarding the continuation of VA-ECMO.
“In emergencies, VA-ECMO should probably be provided to all patients, regardless of whether they have a surrogate or advance directive, particularly when potential benefits are thought to outweigh potential burdens,” the authors concluded. “If the patient fails to recover and is not a candidate for a VAD or cardiac transplantation, VA-ECMO should be discontinued when its burdens outweigh its benefits or potential benefits. How best to proceed respectfully with terminal VA-ECMO discontinuation will vary depending on state law. Clinicians should prioritize their duties to incapacitated patients with no surrogate due to their extreme vulnerability.”
Meltzer EC, Ivascu NS, Edwin MK, Ingall TJ. Should long-term life-sustaining care be started in emergency settings? AMA J Ethics. 2019;21(5):E401-E406.