Background: Patient selection for extracorporeal membrane oxygenation (ECMO) support is complex and associated with variability between clinicians. Disparities exist in ECMO use, with lower utilization in patients who are female, non-white, and have lower income. Limited evidence exists on clinician decisions not to offer ECMO.

Methods: We retrospectively identified charts in the electronic health record (EHR) using text-based search with ‘ECMO’ and related terms from 1-1-2022 to 12-31-2022. Patients were included if 18 or older with a note documenting a decision not to offer veno-arterial (VA)-ECMO support. Charts were reviewed for explicit description of clinician rationale.

Results: 38 patients had documentation of a decision not to offer VA-ECMO support and all but 1 (2.6%) described at least one rationale. The most common rationale against VA-ECMO was perceived poor prognosis (11, 31.4%). Additional rationales included age (8, 21.1%), severe neurologic injury (5, 13.2%), and bleeding risk (4, 10.5%). Ten (26.3%) patients were documented as not offered VA-ECMO due to not being a candidate for transplant or left ventricular assist device (LVAD), and of these 5 (13.2%) had no other rationale documented. Substance use disorder was an independent rationale against ECMO in two patients (5.3%).

Conclusion: Clinician documentation of rationales not to offer VA-ECMO support commonly reflects concern for low likelihood of recovery. However, for some patients, substance use disorder or lack of candidacy for LVAD/transplant alone were cited as rationales against ECMO. Further investigation is warranted into how decision-making regarding temporary life support may be influenced by clinician biases.