Extracorporeal membrane oxygenation (ECMO) represents one of the most ethically challenging and clinically complex therapies used in pediatric critical care. Despite limited guidance and substantial practice variability, center-level approaches to pediatric ECMO decision-making have not been described systematically.

To describe approaches to elements of ECMO decision-making across pediatric cardiac centers participating in Collaborative Research from the Pediatric Cardiac Intensive Care Society (CORE PCICS).

We conducted a cross-sectional survey of all 31 US centers participating in CORE PCICS capturing center-level demographic characteristics and institutional ECMO decision-making practices around candidacy, initiation and discontinuation including approach, timing of considerations, clinical team roles, and family engagement. Responses were analyzed at the center level.

The 31 centers perform a median 20 ECMO cannulations/y (interquartile range, 12-40 cannulations/y). ECMO candidacy decision-making is undertaken on an ad hoc basis in 71% of centers, and 42% of centers defer decisions to a clinical deterioration. Most centers do not have defined well-documented criteria or structured approaches to ECMO initiation or discontinuation decisions (absent in 61% and 71% of centers, respectively). ECMO initiation (74% of centers) and discontinuation (81% of centers) decisions usually are determined by an interdisciplinary clinical team review including intensivists with cardiac surgery expertise in almost all cases. Family involvement varied, only 48% of centers usually involve families in initiation discussions compared with 71% of centers for discontinuation decisions. Although 74% of centers routinely inform families when ECMO is not offered, most centers (68%) do not have a systematic framework for when families disagree with medical team decisions.

Our results show that ECMO candidacy decision-making in US pediatric cardiac centers predominantly is ad hoc, with limited use of standardized or documented criteria for initiation or discontinuation decisions. Although interdisciplinary clinician involvement is common, family engagement remains inconsistent.