Extracorporeal Membrane Oxygenation Ethics: What Is Your Question?*

Amid widespread recognition in critical care of a need to address the ethical dilemmas associated with extracorporeal membrane oxygenation (ECMO) (1), there is a paucity of work that demonstrates what exactly is needed and helpful regarding ethics consultation for pediatric patients receiving ECMO. While some suggest an automatic ethics consult with every ECMO course (2,3), this seems an inefficient use of resources of the generally small pediatric clinical bioethics consult team in most pediatric centers. Siegel et al (4) provide an opportunity to examine what types of ECMO patients have prompted bioethics consultation as a step to understanding how to tailor the consultation to the patient rather than the treatment. In doing so, the question to the ethics consult team becomes "patient-centric" or "issue-centric" rather than vague and poorly focused for the myriad of ethical questions that may occur in any complex PICU therapy, particularly ECMO. In their retrospective cohort study, Siegel et al (4) provide an analysis of ten years (2012–2021) of consult data for 27 ECMO patients who received ethics consultation (4.5% of ECMO patients in their cohort), in a large quaternary pediatric center. Although this is a single center and retrospective look, it offers another point toward larger scale examination of what is needed for clinical ethics support surrounding pediatric ECMO care. To ascertain key aspects of what was a very heterogeneous mix of requests for bioethics support, ethics consults were categorized to find primary and secondary themes of consultation. This, then, allowed the authors to examine a threshold for ethics consultation in their cohort, which was PICU length of stay (> 7.5 wk), longer ECMO duration (> 7 d), and increasing procedures or complications (> 6) (4). While intuitive to any intensivist that a longer more complicated patient ECMO course would escalate ethical dilemmas; this does not necessarily in practice prompt early and proactive ethical consultation. By defining what sort of patient is prompting ethics consults currently, we can start to learn which patient groups might most benefit from bioethics input and in what manner. When one examines the ethical issues present thematically in this analysis they are consistent with previous reviews of ethics consults and overarching themes arising during ECMO care such as burdens of treatment, decisional authority, consent, withdrawal of life-sustaining therapy, and resource considerations, which are in keeping with the ethical dilemmas of non-ECMO ICU patients (3,5,6). However, Siegel et al (4) provide a lens of analysis that is more patient specific to give insight into what ethical questions specific to ECMO were present in their center. This counterpoint provides a degree of examination beyond the general pediatric bioethics issues and begins to reveal potential clinical prompts for bioethics consultation for individual ECMO patients. That the ECMO specific focus for the patients was discontinuation of ECMO, clinical candidacy, and moral distress (4) is again unsurprising given the associated worsened prognosis and increased mortality with long stay complicated courses of ECMO, and yet also revealing from another aspect. This cohort represents only 27 of 601 ECMO patients who received ethics consultation support (4). While this may reflect a long pediatric history of ECMO use and augmented provider facility in working through ethical issues of patients on ECMO, I would suggest that it more likely represents an under-utilization of ethics consultation services and that there is work to be done in engaging more frequently with bioethics support for patients on ECMO given the stakes at hand. I would also, simultaneously, suggest that a blanket ethics consult with every ECMO run would encompass a large volume of potentially unnecessary or unhelpful consults. Although pediatric volumes of ECMO are less than large ECMO units, and some ICUs may find the automatic trigger an important mechanism for their local context, these automatic triggers potentially subtract from other important aspects of clinical ethics work across the hospital. Pediatric ECMO is integrated in intensive care practices as part of standard of care in many pediatric centers, and therefore relatively common in those institutions. By seeking defined-points of patient care for ethics consultation in ECMO patients, one may undertake refining when to prompt an ethics consult early (and possibly preemptively) for those patients most likely to benefit. This provides a focused opportunity to help support teams in maintaining therapeutic relationship, addressing evolving moral distress of the team, and enhancing shared decision making or understanding of patient or surrogate views and values (7–9). Importantly, in the Siegel et al (4) cohort of ethics consults "coaching" offered by the bioethics team, or bioethics facilitated meetings are included. While this can be an important component of enhancing ethical facility in teams, which can decrease moral distress (10), this may represent a different mechanism of supporting teams on ECMO. Educational aspects of understanding ethical justifications surrounding the noted themes of discontinuing ECMO, and ECMO candidacy may reduce distress and lessen the need for a patient specific ethics consult and may be important and helpful aspects of education for ECMO and intensive care teams (1). Such work might also be supported with the development of frameworks and robust decisional processes surrounding ECMO. Ethics interventions, separate from ethical consultation and recommendations for a specific dilemma, would benefit from further study of their impact in supporting ECMO care provision. Adjacent to sweeping statements that all ECMO patients need ethics consults; there are often propositions that all ECMO patients need palliative care consults. By understanding what the nature of ethics consults are one might also enhance understanding of where palliative care consultation, beyond the intensivist primary palliative care skillsets, might best be suited (11). Better understanding of the intersection of end of life and ethical considerations may enhance focused palliative care consultation earlier in an unsuccessful ECMO course. In conjunction, benefits to the family/patient cannot be ascertained from this examination but should be studied (1). Of note, no ethics consults were generated by families in this series, and this may offer additional impetus to both study the family experience and for ethics consult services to reflect on their availability and the patient and family knowledge of their services. The limitations to this sort of description of ethics consults for ECMO is that many aspects of local context may be unaccounted for, it leaves no ability to understand who should have had a consult and did not receive one, and little insight into how other teams may integrate what is a range of bioethics support into their clinical milieu. It begs for multi-institutional follow-up studies to truly inform the field of how ethics consultation is used for pediatric ECMO patients and teams. Without first identifying pervasive ethical issues specific to patients on ECMO, it is difficult to understand how to maximize the benefits of ethics consultation in healthcare provider identification of ethical issues, of its contribution to improved quality of care delivery for ECMO patients, and how it might contribute to institutional ethical climate, enhance wellness of medical providers, or in what way it might alter the family experience. It behooves us to study ethics consultation for ECMO so as to tailor bioethics consults appropriately rather than systematically applying a consult without a guiding question or with only vague exhortations of generalized angst. While I would expect that all bioethics teams would happily attend to any notions of team distress, much like the ongoing clinical refinement of ECMO care, we need to refine and tailor our ethical support. I applaud the study by Siegel et al (4) in approaching a gap in current knowledge surrounding ethics consults supporting patient care during pediatric ECMO, as it provides a potential impetus for larger-scale examination of the issue to garner opportunities to inform best practices for ethics consultation, and ethics support of patients, providers, and families in the ever-expanding utilization of pediatric ECMO. If we bring bioethics integration to ECMO provision with established frameworks, guidelines, and decisional supports, we may also better focus bioethics consultation questions to the patient-specific issue at hand for more meaningful and nuanced answers.