Is It Ethically Justifiable to Withdraw Extracorporeal Membrane Oxygenation Against the Wishes of a Patient With Decision-Making Capacity When Cure Is Not Possible?
Physicians often place patients on extracorporeal membrane oxygenation (ECMO) support because they expect them either to recover with additional support or to become candidates for transplant or mechanical support. If these goals are not met, they may view continued ECMO support as medically inappropriate and recommend its withdrawal. In cases where decisionally-capacitated patients object to the withdrawal of ECMO support, it is not ethically justifiable to do so over their objections. I will offer four arguments supporting this claim based on considerations of medical futility, quality of life, nonmaleficence, and informed consent.
It is well established that clinicians may decline requests for inappropriate interventions, including life-prolonging interventions. This position is supported by major professional organizations,1,2 statutes and regulations,3 and case law.4 As such, the open question is whether providing extracorporeal membrane oxygenation (ECMO) may be considered inappropriate care when cure is not possible.
In 1991, the American Thoracic Society specifically supported the physician’s ability to withdraw life-prolonging interventions over the patient’s objection when the intervention would be highly unlikely to result in meaningful survival.5 In 1997, the Society of Critical Care Medicine (SCCM) supported the clinician’s ability to withdraw interventions that are deemed inappropriate.6 In 1999, the American Medical Association supported a process-based approach to unilateral decisions to withdraw interventions.7 In 2015, the five leading critical care organizations in North America and Europe published the multiorganization policy statement on responding to requests for potentially inappropriate treatments, which provided a robust seven-step process for considering such decisions.1 Most recently, in 2016, SCCM provided guidance regarding when such decisions may be appropriate.8 Because the multiorganization statement allowed for a truncated process when there are significant time constraints, the SCCM Ethics Committee was compelled to provide guidance to ensure providers do not unilaterally limit or withdraw interventions inappropriately when unable to complete the entire seven-step process. SCCM stated, “ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment.” SCCM was clear that there is no obligation to limit or withdraw interventions in such cases, and further clarified that this definition is not exhaustive.