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Ethical dilemmas with the use of ECMO as a bridge to transplantation
Comment
Although extracorporeal membrane oxygenation (ECMO) is most often used to support patients recovering from life-threatening cardiac or pulmonary failure, it is also used as a bridge-to-transplantation therapy for patients with irreversible injury to their lungs.1,2 Ethical dilemmas might arise when patients sustained on ECMO are no longer eligible for transplantation (and thus might no longer be eligible for ECMO), especially if they continue to enjoy an acceptable quality of life.3,4 As an example of such a dilemma, we recently cared for a boy aged 17 years with end-stage respiratory failure after a previous lung transplantation for cystic fibrosis. A second lung transplantation was deemed his only chance for survival. As his pulmonary condition deteriorated, he was placed on venovenous ECMO as a bridge to transplantation. Although this therapy needed continuous monitoring in our intensive care unit (ICU), throughout his stay the patient was fully conscious and interactive with his friends and family. After 2 months on ECMO and the transplantwaiting list, the patient developed hepatomegaly, which led to the diagnosis of post-transplantation lymphoproliferative disease. The diagnosis of this active malignancy with only palliative options for treatment meant that he had to be removed from the transplantwaiting list. As a result, the indication for placing him on ECMO no longer existed. Management of similar cases are seldom discussed in the scientific literature.3 Our possible options included stopping the patient’s ECMO support immediately, maintaining him on ECMO indefinitely, or continuing ECMO but restricting the treatment in ways that might be more ethically and psychologically acceptable for the patient, his family, and the clinicians. Many clinicians were in favour of stopping ECMO immediately. Their ethical rationale was straightforward: ECMO had been begun solely as a bridge to transplantation, but transplantation was no longer an option; therefore, ECMO should be stopped. Others on the clinical team argued that although lung transplantation was no longer possible, the patient was experiencing other substantial benefits from remaining
on ECMO, including a good quality of life, and that his family and friends derived benefits from his continued survival. These clinicians believed that use of ECMO in this patient was justified to continue indefinitely, or at least until complications developed that either proved fatal or substantially degraded the quality of his life. In their view, although ECMO had originally been intended solely as a bridge therapy, in this patient it had become a successful destination therapy, and no different from home ventilation, outpatient dialysis, or an implanted artificial heart. From a patientcentred point of view, the fact that the patient needed to remain in the ICU to receive this therapy was not considered ethically conclusive. Furthermore, concerns arose about the ethical and psychological implications of removing ECMO from a patient who wanted it to continue. Should—or would—clinicians be willing to proceed with the termination of life support in the face of a patient and family who believed that the patient’s life was still of value to him? Although his family had been informed that lung transplantation was no longer possible, and clearly understood the implications of this fact, the thought of choosing a day or a moment when termination of ECMO support would lead immediately to the death of their child was unbearable. The young man had chosen to leave the decision-making to his parents; would he be told when the moment had come? Should he be sedated, or even anaesthetised, beforehand? A third option was to somehow restrict the use of ECMO as a way of delaying or even avoiding the difficult questions related to use of the treatment itself. Clinicians often agree with patients’ families to adopt a so-called no-escalation-of-care strategy at the end of a patient’s life, as shown by decisions not to increase the degree of support provided by mechanical ventilation or vasopressor infusions (although this strategy has been criticised for not being clear about the goals of care).5,6 For the patient described here, a version of this third option was followed—we decided not to replace the ECMO oxygenator as its effectiveness degraded over time. A week or so after this decision was made, the oxygenator gradually failed, and the patient slowly lost consciousness and died.
www.thelancet.com/respiratory Published online July 20, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00233-7
Smetek/Science Photo Library
Ethical dilemmas with the use of ECMO as a bridge to transplantation
Lancet Respir Med 2015 Published Online July 20, 2015 http://dx.doi.org/10.1016/ S2213-2600(15)00233-7
1
Comment
Generally, when managing patients who no longer have the medical indications for which ECMO was initiated, the options of either to stop ECMO as soon as possible or to continue ECMO indefinitely can both be defended by straightforward ethical arguments, despite the fact that they reach opposite conclusions. The path that we chose here, of continuing but restricting the use of lifesupport, is ethically and psychologically complex, yet it did provide an emotionally supportive way to share the moral burden of the decisions with the family when the more ethically straightforward approaches seemed difficult to accept. From a broader societal perspective, however, further issues arise. ECMO is an expensive resource: can we afford to support all patients who might desire ECMO as a destination therapy? Some chemotherapeutic regimens that are expected to extend life by only several months, for example, are similar in cost to the use of ICU care and ECMO.7 How can we justify the wide use of these agents but not ECMO? However, viewing ECMO as a destination therapy could result in unfair use of scarce intensive care resources for some patients over others. If one patient is allowed to stay on ECMO when they no longer have a possibility of transplantation, why should ECMO therapy be denied to patients who have never been transplantation candidates, but who could also enjoy an extension of a desirable quality of life if supported on ECMO indefinitely? Patients with isolated but severe forms of pulmonary disease might value the extra weeks or months that they could survive
2
with ECMO support. Although the few bridge-totransplantation patients are unlikely to become a strain on the availability of ECMO beds, the practice of offering this therapy to everyone with end-stage respiratory failure for an indefinite period could potentially overwhelm the capacity of ICUs. We might soon learn how to manage ECMO patients in less intensive settings; but until then, we must find justifiable ways to address competing goals: providing patients with valued life-sustaining care, serving as conscientious stewards of scarce resources, and choosing among patients in ways that are both compassionate and fair. *Robert D Truog, Ravi R Thiagarajan, Charlotte H Harrison Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA (RDT, RRT, CHH) [email protected] We declare no competing interests. 1
2
3
4 5 6 7
Turner DA, Cheifetz IM, Rehder KJ, et al. Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med 2011; 39: 2593–98. Gupta P, McDonald R, Chipman CW, et al. 20-year experience of prolonged extracorporeal membrane oxygenation in critically ill children with cardiac or pulmonary failure. Ann Thorac Surg 2012; 93: 1584–90. Abrams DC, Prager K, Blinderman CD, Burkart KM, Brodie D. Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults. Chest 2014; 145: 876–82. Meltzer EC, Ivascu NS, Fins JJ. DNR and ECMO: a paradox worth exploring. J Clin Ethics 2014; 25: 13–19. Morgan CK, Varas GM, Pedroza C, Almoosa KF. Defining the practice of “no escalation of care” in the ICU. Crit Care Med 2014; 42: 357–61. Curtis JR, Rubenfeld GD. “No escalation of treatment” as a routine strategy for decision-making in the ICU: con. Intensive Care Med 2014; 40: 1374–76. Bach PB. Indication-specific pricing for cancer drugs. JAMA 2014; 312: 1629–30.
www.thelancet.com/respiratory Published online July 20, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00233-7
Although extracorporeal membrane oxygenation (ECMO) is most often used to support patients recovering from life-threatening cardiac or pulmonary failure, it is also used as a bridge-to-transplantation therapy for patients with irreversible injury to their lungs.1,2 Ethical dilemmas might arise when patients sustained on ECMO are no longer eligible for transplantation (and thus might no longer be eligible for ECMO), especially if they continue to enjoy an acceptable quality of life.3,4 As an example of such a dilemma, we recently cared for a boy aged 17 years with end-stage respiratory failure after a previous lung transplantation for cystic fibrosis. A second lung transplantation was deemed his only chance for survival. As his pulmonary condition deteriorated, he was placed on venovenous ECMO as a bridge to transplantation. Although this therapy needed continuous monitoring in our intensive care unit (ICU), throughout his stay the patient was fully conscious and interactive with his friends and family. After 2 months on ECMO and the transplantwaiting list, the patient developed hepatomegaly, which led to the diagnosis of post-transplantation lymphoproliferative disease. The diagnosis of this active malignancy with only palliative options for treatment meant that he had to be removed from the transplantwaiting list. As a result, the indication for placing him on ECMO no longer existed. Management of similar cases are seldom discussed in the scientific literature.3 Our possible options included stopping the patient’s ECMO support immediately, maintaining him on ECMO indefinitely, or continuing ECMO but restricting the treatment in ways that might be more ethically and psychologically acceptable for the patient, his family, and the clinicians. Many clinicians were in favour of stopping ECMO immediately. Their ethical rationale was straightforward: ECMO had been begun solely as a bridge to transplantation, but transplantation was no longer an option; therefore, ECMO should be stopped. Others on the clinical team argued that although lung transplantation was no longer possible, the patient was experiencing other substantial benefits from remaining
on ECMO, including a good quality of life, and that his family and friends derived benefits from his continued survival. These clinicians believed that use of ECMO in this patient was justified to continue indefinitely, or at least until complications developed that either proved fatal or substantially degraded the quality of his life. In their view, although ECMO had originally been intended solely as a bridge therapy, in this patient it had become a successful destination therapy, and no different from home ventilation, outpatient dialysis, or an implanted artificial heart. From a patientcentred point of view, the fact that the patient needed to remain in the ICU to receive this therapy was not considered ethically conclusive. Furthermore, concerns arose about the ethical and psychological implications of removing ECMO from a patient who wanted it to continue. Should—or would—clinicians be willing to proceed with the termination of life support in the face of a patient and family who believed that the patient’s life was still of value to him? Although his family had been informed that lung transplantation was no longer possible, and clearly understood the implications of this fact, the thought of choosing a day or a moment when termination of ECMO support would lead immediately to the death of their child was unbearable. The young man had chosen to leave the decision-making to his parents; would he be told when the moment had come? Should he be sedated, or even anaesthetised, beforehand? A third option was to somehow restrict the use of ECMO as a way of delaying or even avoiding the difficult questions related to use of the treatment itself. Clinicians often agree with patients’ families to adopt a so-called no-escalation-of-care strategy at the end of a patient’s life, as shown by decisions not to increase the degree of support provided by mechanical ventilation or vasopressor infusions (although this strategy has been criticised for not being clear about the goals of care).5,6 For the patient described here, a version of this third option was followed—we decided not to replace the ECMO oxygenator as its effectiveness degraded over time. A week or so after this decision was made, the oxygenator gradually failed, and the patient slowly lost consciousness and died.
www.thelancet.com/respiratory Published online July 20, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00233-7
Smetek/Science Photo Library
Ethical dilemmas with the use of ECMO as a bridge to transplantation
Lancet Respir Med 2015 Published Online July 20, 2015 http://dx.doi.org/10.1016/ S2213-2600(15)00233-7
1
Comment
Generally, when managing patients who no longer have the medical indications for which ECMO was initiated, the options of either to stop ECMO as soon as possible or to continue ECMO indefinitely can both be defended by straightforward ethical arguments, despite the fact that they reach opposite conclusions. The path that we chose here, of continuing but restricting the use of lifesupport, is ethically and psychologically complex, yet it did provide an emotionally supportive way to share the moral burden of the decisions with the family when the more ethically straightforward approaches seemed difficult to accept. From a broader societal perspective, however, further issues arise. ECMO is an expensive resource: can we afford to support all patients who might desire ECMO as a destination therapy? Some chemotherapeutic regimens that are expected to extend life by only several months, for example, are similar in cost to the use of ICU care and ECMO.7 How can we justify the wide use of these agents but not ECMO? However, viewing ECMO as a destination therapy could result in unfair use of scarce intensive care resources for some patients over others. If one patient is allowed to stay on ECMO when they no longer have a possibility of transplantation, why should ECMO therapy be denied to patients who have never been transplantation candidates, but who could also enjoy an extension of a desirable quality of life if supported on ECMO indefinitely? Patients with isolated but severe forms of pulmonary disease might value the extra weeks or months that they could survive
2
with ECMO support. Although the few bridge-totransplantation patients are unlikely to become a strain on the availability of ECMO beds, the practice of offering this therapy to everyone with end-stage respiratory failure for an indefinite period could potentially overwhelm the capacity of ICUs. We might soon learn how to manage ECMO patients in less intensive settings; but until then, we must find justifiable ways to address competing goals: providing patients with valued life-sustaining care, serving as conscientious stewards of scarce resources, and choosing among patients in ways that are both compassionate and fair. *Robert D Truog, Ravi R Thiagarajan, Charlotte H Harrison Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA (RDT, RRT, CHH) [email protected] We declare no competing interests. 1
2
3
4 5 6 7
Turner DA, Cheifetz IM, Rehder KJ, et al. Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med 2011; 39: 2593–98. Gupta P, McDonald R, Chipman CW, et al. 20-year experience of prolonged extracorporeal membrane oxygenation in critically ill children with cardiac or pulmonary failure. Ann Thorac Surg 2012; 93: 1584–90. Abrams DC, Prager K, Blinderman CD, Burkart KM, Brodie D. Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults. Chest 2014; 145: 876–82. Meltzer EC, Ivascu NS, Fins JJ. DNR and ECMO: a paradox worth exploring. J Clin Ethics 2014; 25: 13–19. Morgan CK, Varas GM, Pedroza C, Almoosa KF. Defining the practice of “no escalation of care” in the ICU. Crit Care Med 2014; 42: 357–61. Curtis JR, Rubenfeld GD. “No escalation of treatment” as a routine strategy for decision-making in the ICU: con. Intensive Care Med 2014; 40: 1374–76. Bach PB. Indication-specific pricing for cancer drugs. JAMA 2014; 312: 1629–30.
www.thelancet.com/respiratory Published online July 20, 2015 http://dx.doi.org/10.1016/S2213-2600(15)00233-7