Article Text

Download PDFPDF
Mitigating ethical conflict and moral distress in the care of patients on ECMO: impact of an automatic ethics consultation protocol
  1. M Jeanne Wirpsa1,2,
  2. Louanne M Carabini3,4,
  3. Kathy Johnson Neely5,6,
  4. Camille Kroll7,
  5. Lucia D Wocial8,9
  1. 1Medical Ethics Program, Northwestern Medicine, Central Region, Chicago, Illinois, USA
  2. 2Spiritual Care and Education, Northwestern Memorial Hospital, Chicago, Illinois, USA
  3. 3Anesthesiology, Northwestern Medicine, Chicago, Illinois, USA
  4. 4Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  5. 5Medical Ethics, Northwestern Medicine, Central Region, Chicago, Illinois, USA
  6. 6Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  7. 7Center for Bioethics and Medical Humanities, Northwestern University, Chicago, Illinois, USA
  8. 8School of Nursing, Indiana University School of Nursing, Indianapolis, Indiana, USA
  9. 9Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, Indiana, USA
  1. Correspondence to M Jeanne Wirpsa, Medical Ethics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; jwirpsa{at}nm.org

Abstract

Aims This study evaluates a protocol for early, routine ethics consultation (EC) for patients on extracorporeal membrane oxygenation (ECMO) to support decision-making in the context of clinical uncertainty with the aim of mitigating ethical conflict and moral distress.

Methods We conducted a single-site qualitative analysis of EC documentation for all patients receiving ECMO support from 15 August 2018 to 15 May 2019 (n=68). Detailed analysis of 20 ethically complex cases with protracted ethics involvement identifies four key ethical domains: limits of prognostication, bridge to nowhere, burden of treatment and system-level concerns. There are three subthemes: relevant contextual factors, the role of EC and observed outcomes. Content analysis of transcripts from interviews with 20 members of the multidisciplinary ECMO team yields supplemental data on providers’ perceptions of the impact of the early intervention protocol.

Results Limited outcome data for ECMO, unclear indications for withdrawal, adverse effects of treatment and an obligation to attend to programme metrics present significant ethical challenges in the care of this patient population. Upstream EC mitigates ethical conflict by setting clear expectations about ECMO as a time limited trial, promoting consistent messaging among multiple services and supporting surrogate decision-makers. When ECMO becomes a ‘bridge to nowhere’, EC facilitates decision-making that respects patient values yet successfully sets limits on non-beneficial use of this novel therapy.

Conclusion Data from this study support the conclusion that ECMO poses unique ethical challenges that necessitate a standardised protocol for early, routine EC—at least while this medical technology is in its nascent stages.

  • clinical ethics
  • decision-making
  • end of life care
  • ethics committees/consultation
  • ethics

Statistics from Altmetric.com

Footnotes

  • Contributors All of the listed authors have met criteria for substantial contributions to the following: (1) the conception and design of the study, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be submitted. The authors received no assistance in writing and editing the manuscript. Additional contributors to the study who do not meet criteria for authorship are listed in the acknowledgements section. Specific author contributions: MJW: conceptualisation, methodology, visualisation, formal analysis, investigation, supervision, writing (original draft, review and editing); LMC: conceptualisation, methodology, visualisation, writing (original draft, review and editing); KJN: conceptualisation, methodology, project administration, writing (original draft, review and editing); CK: formal analysis, data curation, visualisation, writing (review and editing); LDW: conceptualisation, writing (review and editing).

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was reviewed by the institution’s institutional review board, which determined that neither the extracorporeal membrane oxygenation clinical documentation data nor interviews met the criteria for human subjects research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Other content recommended for you