“Almost every action within the medical setting either explicitly or implicitly contains two judgements, one ethical and one scientific, and there is constant interplay between what is technically possible and what is morally desirable.”
Extracorporeal life support (ECLS) is an advanced form of life support for patients whose heart and lungs do not respond to conventional life support, such as drugs that stimulate the heart to beat and mechanical ventilation to help the lungs work. It uses a machine to bypass the heart and lungs. A blood pump and oxygenator outside the body takes the patient’s blood, removes carbon dioxide and adds oxygen. This processed blood is pumped back into the patient, doing the work of the heart, the lungs or both.
Traditionally used in newborns and children for rescue situations, ECLS now represents the standard approach for an ever-expanding number of childhood medical conditions. Furthermore, enthusiasm for its potential use with adult patients is growing.
However, technological advancements and expanding indications for ECLS are outpacing ethical considerations. Being attentive to the ethical dilemmas faced in the use of ECLS may mitigate the burdens for patients, families, staff members and healthcare systems. We need to ask: just because we can use this, should we?
Drs. Jonna D. Clark and Mithya Lewis-Newby are faculty in the Treuman Katz Center for Pediatric Bioethics and clinicians in the Division of Pediatric Critical Care Medicine. To stimulate research around the ethical implications of ECLS, in 2012 they formed a group of 14 providers and researchers who meet every two to four weeks. This group, the Seattle Ethics in ECLS (SEE) Consortium, spent last year identifying the important ethical questions that exist around the use of ECLS, setting research priorities and choosing the best approaches to tackle these research questions.
“Bioethics is entwined with all aspects of advanced life support. In addition to traditional ethical questions, bioethics can also more inclusively include topics around communications, family and staff support and decision making,” says Clark. “We formed this group to try to understand the ethical dilemmas we had encountered and develop approaches to address these dilemmas. Ultimately we want to improve the quality of ECLS-related medical care.”
What makes ECLS so complex?
- ECLS is resource-intensive, requiring highly trained medical personnel and expensive equipment.
- ECLS is used in life-or-death medical situations, when decisions may be desperate.
- Families typically must make ECLS decisions within very short time frames (minutes or days) when under stress.
- ECLS involves significant risk, with serious complications being common (including stroke and other forms of brain injury).
- There is commonly great prognostic uncertainty.
“Each factor may exist in isolation in other areas of medicine; however, in ECLS all of these factors collide into a ‘perfect storm’ that creates distress for the patient, family and the healthcare providers,” Lewis-Newby says.
The group identified 38 unique research questions addressing ethical dimensions of ECLS in the domains of societal decision making, bedside decision making, patient/family communication, medical team dynamics, research design and implementation. The SEE consortium has prioritized its research goals with an overarching aim of ensuring:
- Respect for the well-being of patients, families and staff
- That technological advancement of ECLS does not come at the cost of undue burdens for patients and families
- That resources are allocated justly and responsibly
The next step for the SEE Consortium will be to develop a specific research project to advance.