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Jucker JA, Cannizzaro V, Kirsch RE, Streuli JC, De Clercq E. Between hope and disillusionment: ECMO seen through the lens of nurses working in a neonatal and paediatric intensive care unit. Nurs Crit Care 2024. [PMID: 38511290 DOI: 10.1111/nicc.13051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 12/06/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Using extracorporeal membrane oxygenation (ECMO) in paediatric and neonatal intensive care units (PICU/NICU) creates ethical challenges and carries a high risk for moral distress, burn out and team conflicts. AIM The study aimed to gain a more comprehensive understanding of the underlying factors affecting moral distress when using ECMO for infants and children by examining the attitudes of ECMO nurses. METHODS Four focus groups discussions were conducted with 21 critical care nurses working in a Swiss University Children's Hospital. Purposive sampling was adopted to identify research participants. The data were analysed using reflexive thematic analysis. RESULTS Unlike "miracle machine" stories in online media reports, specialized nurses working in PICU/NICU expressed both their hopes and fears towards this technology. Their accounts also contained references to events and factors that triggered experiences of moral distress: the unspeakable nature of the death of a child or infant; the seemingly lack of honest and transparent communication with parents; the apparent loss of situational awareness among doctors; the perceived lack of recognition for the role of nurses and the variability in end-of-life decision-making; the length of time it takes doctors to take important treatment decisions; and the resource intensity of an ECMO treatment. CONCLUSION The creation of a multidisciplinary moral community with transparent information among all involved health care professionals and the definition of clear treatment goals as well as the implementation of paediatric palliative care for all paediatric ECMO patients should become a priority if we want to alleviate situations of moral distress. RELEVANCE FOR CLINICAL PRACTICE The creation of a multidisciplinary moral community, clear treatment goals and the implementation of palliative care for all paediatric ECMO patients are crucial to alleviate situations of moral distress for nurses, and thus to improve provider well-being and the quality of patient care in PICU/NICU.
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Affiliation(s)
- Jovana A Jucker
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zürich, Switzerland
- Department of Neonatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Roxanne E Kirsch
- Department of Bioethics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jürg C Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, Zürich, Switzerland
- Stiftung Dialog Ethik, Zürich, Switzerland
| | - Eva De Clercq
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
- Stiftung Dialog Ethik, Zürich, Switzerland
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Moynihan KM, Taylor LS, Siegel B, Nassar N, Lelkes E, Morrison W. "Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation. Front Pediatr 2024; 11:1325207. [PMID: 38274466 PMCID: PMC10808631 DOI: 10.3389/fped.2023.1325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO). Analysis Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed. Discussion Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.
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Affiliation(s)
- Katie M. Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lisa S. Taylor
- Office of Ethics, Boston Children’s Hospital, Boston, MA, United States
| | - Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Natasha Nassar
- Clinical and Population Translational Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Efrat Lelkes
- Department of Pediatrics, MaineGeneral Medical Center, Augusta, ME, United States
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Divisions of Critical Care and Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Bibler TM, Zainab A. Withdrawing extra corporeal membrane oxygenation (ECMO) against a family's wishes: Three permissible scenarios. J Heart Lung Transplant 2023; 42:849-852. [PMID: 36972748 DOI: 10.1016/j.healun.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
The ethical permissibility of unilaterally withdrawing life-sustaining technologies has been a perennial topic in transplant and critical care medicine, often focusing on CPR and mechanical ventilation. The permissibility of unilateral withdrawal of extracorporeal membrane oxygenation (ECMO) has been discussed sparingly. When addressed, authors have appealed to professional authority rather than substantive ethical analysis. In this Perspective, we argue that there are at least three (3) scenarios wherein healthcare teams would be justified in unilaterally withdrawing ECMO, despite the objections of the patient's legal representative. The ethical considerations that provide the groundwork for these scenarios are, primarily: equity, integrity, and the moral equivalence between withholding and withdrawing medical technologies. First, we place equity in the context of crisis standards of medicine. After this, we discuss professional integrity as it relates to the innovative usage of medical technologies. Finally, we discuss the ethical consensus known at the "equivalence thesis." Each of these considerations include a scenario and justification for unilateral withdrawal. We also provide three (3) recommendations that aim at preventing these challenges at their outset. Our conclusions and recommendations are not meant to be blunt arguments that ECMO teams wield whenever disagreement about the propriety of continued ECMO support arises. Instead, the onus will be on individual ECMO programs to evaluate these arguments and decide if they represent sensible, correct, and implementable starting points for clinical practice guidelines or policies.
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Affiliation(s)
- Trevor M Bibler
- Center for Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.
| | - Asma Zainab
- Department of Cardiovascular Anesthesia, Weill Cornell Medical College, New York, New York; Intensivist Cardiovascular Surgical ICU, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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Kon AA. Withdrawal of ECMO Support over the Objections of a Capacitated Patient can be Appropriate. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:30-32. [PMID: 37220383 DOI: 10.1080/15265161.2023.2201218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Alexander A Kon
- Community Children's
- University of Washington School of Medicine
- University of California San Diego School of Medicine
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Kingsley J, Berkman ER, Derrington SF. Battle of the Bridge: Ethical Considerations Related to Withdrawal of ECMO Support for Pediatric Patients over Family Objections. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:32-35. [PMID: 37220381 DOI: 10.1080/15265161.2023.2201237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Kim EJ, Marron JM. Can the Extraordinary Become Ordinary? Re-Examining the Ethics of ECMO-DT. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:59-61. [PMID: 37220377 DOI: 10.1080/15265161.2023.2201214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Eric J Kim
- Harvard Medical School Center for Bioethics
- NYU Grossman School of Medicine
| | - Jonathan M Marron
- Harvard Medical School Center for Bioethics
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center
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Morrison W, Moynihan K. Personalizing Care and Communication at the Limits of Technology. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:41-43. [PMID: 37220364 DOI: 10.1080/15265161.2023.2201207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Wynne Morrison
- The Children's Hospital of Philadelphia
- University of Pennsylvania
| | - Katie Moynihan
- Harvard Medical School
- Boston Children's Hospital
- The University of Sydney
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Wilkinson D, Fraser J, Suen J, Suzuki MK, Savulescu J. Ethical Withdrawal of ECMO Support Over the Objections of Competent Patients. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:27-30. [PMID: 37220370 DOI: 10.1080/15265161.2023.2201194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
| | | | | | | | - Julian Savulescu
- Murdoch Children's Research Institute
- National University Singapore Centre for Biomedical Ethics
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Fleck LM. ECMO: What Would a Deliberative Public Judge? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:46-48. [PMID: 37220371 DOI: 10.1080/15265161.2023.2201197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Callies DE. Unilateral ECMO Withdrawal and the Argument From Distributive Justice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:72-74. [PMID: 37220361 DOI: 10.1080/15265161.2023.2201227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Karches KE. Why Deny ECMO-DT to the Incapacitated? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:70-72. [PMID: 37220379 DOI: 10.1080/15265161.2023.2201216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Hollander S, Char D. A Bridge to Nowhere. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:54-56. [PMID: 37220366 DOI: 10.1080/15265161.2023.2201228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Doernberg SN, Soled DR, Truog RD. Ethical Issues in the Transition to ECMO as a Destination Therapy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:18-20. [PMID: 37220369 DOI: 10.1080/15265161.2023.2201193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
| | - Derek R Soled
- Brigham and Women's Hospital
- Harvard Medical School
- Boston Children's Hospital
- Boston Medical Center
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Rubin J, Robinson E, Rubin EB. The Human and Humanity that Differentiate Withholding from Withdrawing Life-Sustaining Therapy: An ECMO Bridge to Nowhere. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:62-64. [PMID: 37220365 DOI: 10.1080/15265161.2023.2201206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Jonah Rubin
- Harvard Medical School
- Massachusetts General Hospital
| | | | - Emily B Rubin
- Harvard Medical School
- Massachusetts General Hospital
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Hutchison PJ, Joshi N, Wasson K. When the Bridge Crumbles: Balancing ECMO-DT With Transplant Program Needs. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:49-51. [PMID: 37220357 DOI: 10.1080/15265161.2023.2201203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Kondrat A. "Sorry, but the Ethicist Said Your Life Isn't Actually Worth Living": Misunderstanding Ethics and the Role of the Ethics Consultant. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:24-27. [PMID: 37220375 DOI: 10.1080/15265161.2023.2201234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Andrist E. Fairly Distributing the Distributive Justice Argument Permits Stopping ECMO. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:65-67. [PMID: 37220363 DOI: 10.1080/15265161.2023.2201226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Erica Andrist
- Center for Bioethics, Harvard Medical School
- University of Michigan
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Courtwright AM. The Moral Relevance of ECMO Bridge Maintenance. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:52-54. [PMID: 37220367 DOI: 10.1080/15265161.2023.2201209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Batten JN, Dzeng E, Finder S, Blythe JA, Nurok M. When Critically Ill Patients with Decision Making Capacity and No Further Therapeutic Options Request Indefinite Life Support. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:21-23. [PMID: 37220368 DOI: 10.1080/15265161.2023.2201208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Frader J, Paquette E, Michelson K, Morgan E. Bridge or Destination: Ethical Complexity, Emotional Unrest. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:44-46. [PMID: 37220376 DOI: 10.1080/15265161.2023.2201211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Joel Frader
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - Erin Paquette
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - Kelly Michelson
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - Elaine Morgan
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
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Kirsch RE. The Divergence of Technical and Human Teleology. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:38-41. [PMID: 37220378 DOI: 10.1080/15265161.2023.2201213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Derse AR. The ECMO Bridge and 5 Paths. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:1-4. [PMID: 37220356 DOI: 10.1080/15265161.2023.2202611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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