Editor's note: This popular story from the Daily Briefing's archives was republished on June 30, 2023.
Extracorporeal membrane oxygenation (ECMO) machines can prolong the lives of patients whose lungs have been destroyed by illness. However, without a transplant or recovery, some patients may be stuck with the device indefinitely, leaving them on "a bridge to nowhere" and limiting their quality of life, Daniela Lamas, a pulmonary and critical care physician at Brigham and Women's Hospital, writes in the New York Times.
ECMO has been used for patients with lung and heart failure for decades. But during the pandemic, ECMO became a "a last-ditch intervention" for Covid-19 patients whose lungs were so destroyed by the disease that they needed lung bypass to recover, Lamas writes.
Now, the use of ECMO has become more common, particularly among patients waiting for heart or lung transplants or for those suffering from respiratory failure due to pneumonia or asthma. However, ECMO is not designed for long-term use.
Instead, many doctors see ECMO as "a bridge rather than a destination," Lamas writes, especially since there are many complications that can occur while a patient is on the device. Patients using the device are at risk of life-threatening blood clots, hemorrhage, or stroke. They also need constant monitoring and regular—often daily—blood transfusions.
However, when neither recovery nor a transplant is possible for patients, ECMO can become a "bridge to nowhere." The machine can prolong a patient's life, but it is one "without quality" since they will no longer be able to live outside the ICU, Lamas writes.
Although doctors make the risks of ECMO clear to patients and their families before the treatment is started, this still does not prepare them for the difficult decision of determining when and whether the treatment should be stopped when there is no other path forward.
According to Lamas, whether ECMO should be used indefinitely for patients who have no chance of recovery or transplant is one of the "profoundly difficult questions and unimaginable realities" plaguing modern medicine.
For some physicians, once transplant or recovery is no longer possible, it no longer makes sense to keep a patient on ECMO. Unlike a ventilator, which patients can stay on indefinitely, ECMO is "the riskiest and most labor-intensive mode of life support we have" and more time on the device "means only more suffering," Lamas writes.
However, other doctors have argued that there is no reason not to have a patient on ECMO indefinitely, especially if their quality of life is otherwise acceptable.
"When I've encountered situations like these, there are always people who say, quite reasonably, that we are not here just to keep people alive on machines," said Robert Truog, a pediatric ICU doctor and director of Harvard Medical School's Center for Bioethics. "But then I think, why not? Why not go until it can't be done anymore or he or his family tell us to stop?"
"There's this mentality that 'this can't go on,' and I question the ethical soundness of that," said Kenneth Prager, the director of clinical ethics at Columbia University Irving Medical Center. "Why can't it? Especially when we consider the considerable resources expended on numerous non-ECMO patients with no chance of survival who may spend weeks or months in the I.C.U. at the insistence of their families."
Another potential issue with indefinite use is that ECMO machines are limited resources. Not all hospitals have one, and the ones that do typically only have a few available. "If we were to continue patients on ECMO even after they are declined transplants, then should we offer the machine to other people who are not transplant candidates to prolong their lives?" Lamas asks.
In the end, there are no easy answers when it comes to prolonging ECMO usage, especially as physicians try to minimize both physical and emotional suffering.
"[D]eferring the decision of when to say enough to a devastated patient and beleaguered loved ones could itself be a kind of cruelty," Lamas writes, but "for some patients, maybe the greater cruelty is forcing them to come to terms with what is essentially a death sentence" without the ECMO machine.
"[H]ere in the netherworld that our interventions have created, there are no clear answers," she writes. (Lamas, New York Times, 11/22)
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