The experience of being an 'extracorporeal membrane oxygenation' relative within the CESAR trial

The lived experience by patients and family members of extracorporeal membrane oxygenation: A qualitative study

OBJECTIVE

To examine the lived experience of extracorporeal membrane oxygenation (ECMO) by patients and their families, and their relationship with intensive care clinicians.

RESEARCH METHODOLOGY

Semi-structured interviews were conducted with six patients who had received ECMO and with four of their family members. The data were analysed narratively using a constant comparative method.

SETTING

Patients were treated at a major acute care hospital in British Columbia between 2014 and 2021. ECMO was used either as a bridge to recovery or to organ transplant. Four had family members bedside throughout, while two had virtual visits due to COVID-19 infection control measures.

FINDINGS

ECMO was experienced through a triad of relationships between the patient, key family members and key clinicians. The strength, directionality and focus of these relationships shifted during therapy and realigned once ECMO was removed. The largest shift involved family members. Post-ECMO, patients relied almost entirely on spouses, adult children and clinical team members to reconstruct their experience. The connection between families and clinical team members was limited and changed little.

CONCLUSIONS

The lived experience of ECMO was complex in ways yet to be comprehensively reported in the literature. This technology had particular impact on family members when ECMO was used as a bridge to transplant and where run times extended to multiple weeks. COVID-19 infection control restrictions further complicated how this technology was experienced. Findings from this study highlight the importance of intensive care nurses recognising the critical role family members play as witnesses whose experiences later allow patients to make sense of their journey post-discharge.

A qualitative exploratory case series of patient and family experiences with ECPR for out-of-hospital cardiac arrest

Objective

There is currently no existing data examining the opinions of patients and families after treatment with extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). We sought to interview family members and patients to learn from their experiences and satisfaction with treatment.

Methods

We contacted family members and survivors for all cases treated with ECPR for refractory OHCA at St. Paul’s Hospital between January 2014 and July 2018. We performed semi-structured interviews with participants, specifically within the topics of: information sharing (including impressions of an ECPR informational pamphlet), prognostication, organ donation, and perceived value of ECPR. Due to low participant enrolment, we described all interviews in a narrative approach.

Results

Within the study period, there were 23 OHCAs treated with ECPR; two survivors and three family members agreed to participate. Participants were satisfied with the treatment provided, including information sharing and prognostication. There were mixed opinions about the best method of information-sharing (verbal vs written), as well as the timing of organ donation conversations. All participants believed ECPR for OHCA to be of high value.

Conclusion

Patient’s conveyed satisfaction with ECPR treatment, with mixed views on the best information sharing strategy. Further study is needed to define the optimal methods and timing for discussions of organ donation, especially for treatments of with a relatively low likelihood success.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Stressors and strains of next of kin of patients with ARDS in intensive care: A qualitative interview study using a stress-strain approach

OBJECTIVES

This study aims to explore and analyse the stressors and strains of next of kin of acute respiratory distress syndrome (ARDS) patients during their stay in the intensive care unit utilising the stressors and strain approach as a theoretical framework.

METHODS

Data collection was performed as semi-standardised qualitative interviews. 35 families of patients with ARDS were approached when visiting the intensive care unit. Participants were recruited until thematic saturation was reached; finally, 17 persons (age ranging from 26 to 71 years, nine women) took part. Systematic content analysis was conducted on the theoretical foundations of the stressors and strain approach.

FINDINGS

Numerous stressors were identified; they can be divided into three main categories: in relation to organising the visit, occurring during the visit and arising at home. These stressors were reported highly consistently throughout participants. However, the strains resulting from these stressors were varying in manifestation and level.

CONCLUSIONS

This study explores the manifold stressors and strains of next of kin of a critically ill patient. Some stressors are inherent to the life-threatening condition of a family member; others arise from the health care system and could be modified. The level of strain experienced depends on social support, individual coping skills and life circumstances.

Identification and prevalence of PTSD risk factors in ECMO patients: A single centre study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is one of the most invasive rescue therapies for acute heart and/or lung failure. Survivors have high rates of adverse mental health outcomes, such as post-traumatic stress symptoms (PTSS) and manifest post-traumatic stress disorder (PTSD). Yet no study to date has identified and explored PTSD risk factors in these patients.

OBJECTIVES

The primary aim of this study was to determine and explore post-traumatic stress risk factors for patients treated with ECMO. It also aimed to provide a baseline profile for future hypothesis testing with respect to risk factor exposure, level of exposure and post-traumatic stress outcomes in these patients.

METHODS DESIGN

Retrospective cohort study.

SETTING

The study was conducted at the Alfred Hospital Melbourne, Australia.

PARTICIPANTS

Patients were selected in 2012 from an Intensive Care Unit (ICU) registry that prospectively included all patients admitted to ICU and treated with ECMO.

DATA EXTRACTION AND ANALYSIS

Data were extracted from the ICU ECMO registry, ICU and ward charts, progress notes, referrals, drug charts and discharge letters. Data were descriptively analysed.

RESULTS

Patients treated with ECMO are exposed to almost all investigated PTSD risk factors. These included psychiatric history (psychiatric comorbidities), admission to ICU and treatment (prolonged ventilation during prolonged ICU stay), and drug therapy (all patients treated with PTSD risk related drugs).

CONCLUSION

ECMO patients are exposed to PTSD risk factors such as young age, mechanical ventilation, drug administration, delirium and agitation. Younger age, heterogeneous conditions, profound illness severity and prolonged ICU stay describe the case complexity of patients and may explain these findings. Patients in ICU are increasingly conscious during active treatment and this may have positive or negative psychological effects. "Awake" ECMO in which patients are conscious while on active life support may represent a unique PTSD risk factor in this perspective.