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Practice Patterns and Ethical Considerations in the Management of Venovenous Extracorporeal Membrane Oxygenation Patients

An International Survey

Abrams, Darryl MD1,2; Pham, Tài MD3,4,5; Burns, Karen E. A. MD3,4,5; Combes, Alain MD6,7; Curtis, J. Randall MD8,9,10; Mueller, Thomas MD11; Prager, Kenneth M. MD1; Serra, Alexis MD1,2; Slutsky, Arthur S. MD3,4,5; Brodie, Daniel MD1,2; Schmidt, Matthieu MD6,7 on behalf of the International ECMO Network (ECMONet)

doi: 10.1097/CCM.0000000000003910
Clinical Investigation: PDF Only

Objectives: To characterize physicians’ practices and attitudes toward the initiation, limitation, and withdrawal of venovenous extracorporeal membrane oxygenation for severe respiratory failure and evaluate factors associated with these attitudes.

Design: Electronic, cross-sectional, scenario-based survey.

Setting: Extracorporeal membrane oxygenation centers affiliated with the Extracorporeal Life Support Organization and the International Extracorporeal Membrane Oxygenation Network.

Subjects: Attending-level physicians with experience managing adult patients receiving venovenous extracorporeal membrane oxygenation.

Interventions: None.

Measurements and Main Results: Five-hundred thirty-nine physicians in 39 countries across six continents completed the survey. Factors that influenced the decision to limit extracorporeal membrane oxygenation initiation included older patient age (46.9%), additional organ failures (37.7%), and prolonged mechanical ventilation (35.1%). Patient comorbidities (70.5%), patient’s wishes (56.0%), and etiology of respiratory failure (37.7%) were factors that influenced the decision to withdraw extracorporeal membrane oxygenation. In multivariable analysis, factors associated with increased odds of withdrawing life-sustaining therapies included pulmonary fibrosis, stroke, surrogate’s desire to withdraw, lack of knowledge regarding patient’s or surrogate’s wishes in the setting of fibrosis, not initiating extracorporeal membrane oxygenation in the baseline scenario, and respondent religiosity. Factors associated with decreased odds of withdrawal included practicing in an environment where it is not legally possible to make decisions against patient or surrogate wishes. Most respondents (90.5%) involved other physicians in treatment decisions for extracorporeal membrane oxygenation patients, whereas only 53.2%, 45.3%, and 29.5% of respondents involved surrogates, awake patients, or bedside nurses, respectively.

Conclusions: Patient and physician-level factors were associated with decision-making regarding extracorporeal membrane oxygenation initiation and withdrawal, including patient prognosis and knowledge of patient or surrogate wishes. Respondents reported low rates of engaging in shared decision-making when managing patients receiving extracorporeal membrane oxygenation.

1Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY.

2Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY.

3Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.

4Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada.

5The University of Toronto, Toronto, ON, Canada.

6Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, Paris, France.

7Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, Paris, France.

8Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA.

9Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.

10Department of Bioethics and Humanities, University of Washington, Seattle, WA.

11Department of Internal Medicine II, University Hospital of Regensburg, Regensburg, Germany.

Drs. Brodie and Schmidt are co-senior authors.

International ECMO Network (ECMONet) board members are: Daniel Brodie, Chair of Executive Committee; and Arthur S. Slutsky, Chair of Scientific Committee. Executive Committee Members are: Laurent Brochard, Daniel Brodie, Alain Combes, Eddy Fan, Niall Ferguson, John Fraser, Carol Hodgson, Danny McAuley, Alain Mercat, Thomas Mueller, Vin Pellegrino, Antonio Pesenti, Michael Quintel, V. Marco Ranieri, and Arthur S. Slutsky.

Drs. Abrams, Combes, Curtis, Mueller, Serra, Brodie, and Schmidt were responsible for study design and development of the questionnaire. Drs. Abrams, Serra, and Schmidt were responsible for data collection. Drs. Pham, Burns, and Schmidt performed data analysis. Drs. Abrams, Pham, Burns, Brodie, and Schmidt drafted the article. Drs. Pham and Schmidt designed the figures. Drs. Abrams, Pham, Burns, Combes, Curtis, Mueller, Prager, Serra, Slutsky, Brodie, and Schmidt reviewed and edited the article. Dr. Abrams collated edits and prepared the article for submission. All authors approve the final version. The corresponding author (Dr. Schmidt) had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Combes reports grants and personal fees from Maquet, grants and personal fees from Baxter, personal fees from Hemovent, outside the submitted work. Dr. Slutsky reports personal fees from Baxter Healthcare, personal fees from Xenios/NovaLung, personal fees from Maquet Critical Care, outside the submitted work. Dr. Brodie reports fees to his university from ALung Technologies, personal fees from Baxter and anticipated fees from Breethe, Inc. unpaid association with Hemovent, outside the submitted work. Dr. Schmidt reports personal fees from Getinge, personal fees from Drager, outside the submitted work. Drs. Abrams and Brodie disclosed off-label product use of extracorporeal membrane oxygenation for severe respiratory failure. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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