Ethical Dilemmas in Extracorporeal Membrane Oxygenation (ECMO) Público

Abstract

Abstract

The ethics of medical decision making can be complex. Modern medicine has the ability to keep patients alive for extended amounts of time on maximal support. One such technology that is being used with increased frequency is Extracorporeal Membrane Oxygenation (ECMO). ECMO is a potentially life-saving technology that is used to provide artificial cardiac and pulmonary support to patients. ECMO use in the United States in on the rise, since 2006 there has been a 400% increase in the use of ECMO in intensive care units (Mosier, 2015). According to the Extracorporeal Life Support Organization (ESLO) registry, ECMO was used in over 5,000 cases in 2014 (Makdisi, 2015). This substantial increase of patients treated with ECMO and the expansion of indications for its use raises many questions about the use of ECMO some of which will be surveyed in this paper (Makdisi,2015). It should be noted that ECMO is supportive therapy, meaning that it acts to sustain life and that it does not necessarily cure the underlying pathology.

Over the last 50 years, medical technology has outpaced the understanding of most patients and their families; yet they are the primary decision makers. This presents ethical dilemmas for patients, surrogates, and health care teams; many of the dilemmas that ECMO poses are novel in that they are specific to this technology. My thesis approach will involve identifying ethical dilemmas that arise in caring for ECMO patients. My recommendations will involve creation of an ECMO Physician Orders for Life Sustaining Treatment (ECMO-POLST) and rigorous use of ethics committees prior to the initiation of treatment and throughout the patient’s trial of ECMO. In instances in which extraordinary care or newer medical technologies are being used, a different approach is required in order to mitigate ethical dilemmas and provide quality care for patients.

Table of Contents

TABLE OF CONTENTS

Chapter I: Introduction to ECMO and its application…………………….1

Chapter II: Ethical Dilemma- Moral Distress……………………………11

Chapter III: Ethical Dilemma – Resource Allocation……………………19

Chapter IV: Ethical Dilemma- Informed Consent………………………..25

Chapter V: Ethical Dilemma-Decision Making Quandaries……………...29

Chapter VI: Ethical Dilemma- Appropriateness of ECPR……………….38

Chapter VII: Discussion and Future Recommendations…………………43

Bibliography……………………………………………………………….56

Appendix: Figures/Forms

Figure 1: The number of centers contributing to the ELSO registry and cases per year……………………………………………………………………2

Figure 2: Recent ECMO outcomes for all patient subgroups…………3

Figure 3: Costs of ECMO for survivors and non-survivors based on indication for ECMO…………………………………………………………………22

Figure 4: Proposed ECMO-POLST…………………………………..49

Figure 5: Proposed Ethics Daily Rounding/Consultation Form……...55

About this Master's Thesis

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School	Laney Graduate School
Department	Bioethics
Degree	M.A.
Submission	Master's Thesis
Language	English
Research Field	Ethics Health Sciences, Medicine and Surgery Health Sciences, Medical Ethics
Palavra-chave	Ethics ECMO
Committee Chair / Thesis Advisor	Joel Zivot, Emory University Kathy Kinlaw, Emory University
Committee Members	John Banja, Emory University

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