Finding a Bridge to Somewhere: An Ethical Framework for Veno-Arterial Extracorporeal Membrane Oxygenation Decisions

Extracorporeal membrane oxygenation (ECMO) is an established therapy for the management of acute cardiopulmonary failure. A substantial concern when considering ECMO therapy is whether the patient will recover enough function to be weaned from support and survive to discharge. The concept of “a bridge to nowhere” is where a patient is supported on a therapy for which there is no hope for recovery and would, by definition, immediately die if support is discontinued—a somewhat unique concept in clinical medicine, but often considered when considering short-term mechanical support for acute heart and/or lung failure. Much like initiating mechanical ventilator support in patients who have no chance of meaningful recovery, there are concerns about embarking on or continuing with ECMO support in patients in whom recovery is unlikely. The purpose of this chapter is to review the ethical foundation and principles to support the clinical decision-making process when there are concerns regarding the initiation, continuation, or withdrawal of this highly invasive, resource-intensive life-support technology. Specific attention will be given to well-established principles of the ethical application of advanced life support and how to appropriately limit offering or continuing therapies for which meaningful outcomes are unlikely or further support is considered futile.