Continuing ECMO without Potential Recovery, Transplant, or Device.

TOPIC IMPORTANCE: The use of extracorporeal membrane oxygenation (ECMO) as a temporary bridge to recovery, transplant or durable device implant is widely accepted. Major unease remains for patients already on ECMO progressing in ways that preclude recovery, transplantation, or device. A substantial number of clinicians argue that when a patient no longer qualifies for recovery, transplantation, or device; ECMO should be withdrawn, even over patient or authorized decision-maker objection. OVERVIEW: In this manuscript, we assess ethical arguments for this unilateral withdrawal position, make counterarguments in opposition to unilateral withdrawal, and offer practical suggestions for resolving conflicts. We critique four ethical rationales for unilaterally discontinuing ECMO - (1) the original design and purpose of ECMO; (2) medically inappropriate treatment; (3) the equivalency thesis: because withholding is permissible, so is withdrawing; and (4) resources, expense, and distributive justice. In addition, we review legal issues and outline practical steps for conflict resolution.