ECMO Ethics

amiodarone3 · Jun 20, 2014

Well. In brief, don't throw the towel in-move units if need be but don't let it get to you. It is the nature of our work, being emotionally challenged and put in situations that are ******.

However, in my experience no. It is a last ditch effort and the doctors that consent the patient (or families rather) are fully aware of what is happening and they explain this to the family. On that note-you should be able to discuss that because the family and whoever is making the patient's decisions should know what the situation is about, especially at that point and time. Now-on that note-yes, it raises questions as to "why", but then again working in an ICU environment should in general. What "we do" in an ICU is not always ethical and is not always pleasant. Yes sometimes it is about numbers but those numbers are statistics that can be used to help. That is medicine.

But it also largely has to do with our society, the american culture has difficulties letting go and therefore wants EVERYTHING to be done NOW to save someone. When it would often times be more appropriate to go home with some dignity and peace.

food for thought. don't give up

Kettek53 · Jun 20, 2014

That is what is so hard for me to wrap my head around: it's not always ethical. I understand there are always going to be those families out there that are going to demand everything be done, no matter what the circumstance I have also seen families that are ready to let go of their 40-something family member, but then convinced to continue treatment because the doc is painting a picture of roses and butterflies if they just give the patient a couple more days. This is what keeps me up at night, and I really wish I could let it go. Is there anyone that we can't "save" anymore?

amiodarone3 · Jun 20, 2014

well, that is the job you/we all chose. sorry to be blunt but it is true. nursing is difficult not for the hours, not for the tasks or attention to detail, not for being spit at, cursed at or cleaning s**t nor working for weeks to no end to see a patient suddenly expire...what makes this profession difficult is seeing humanity at its most elemental core.

Haha, there is always someone to save when money depends on it!

WoosahRN, MSN, RN · Jun 20, 2014

I am an ECMO Specialist in PICU/NICU and I'm a bedside PICU nurse. But my comment is more to nursing ethics in general. If you find that you have a hard time with one area, most likely that's not going to change, and as you found, will get worse. I have found that I don't agree with saving every micro-preemie. I ethically don't think we need to be doing aggressive and invasive interventions for months for a poor QOL. Granted I'm biased as I see a lot of NICU grads come through PICU. And this is not to disrespect NICU nurses. I work along side them. It's a general ethical dilemma for me. Because of that I don't think I could ever work NICU. That's just the line I draw. You might have to draw some lines too.

Maybe taking care of the ECMO patients isn't something you can do all the time. Or you need to find a way to detach as you mention. Focus on the skills, not the what ifs. That can be hard and again might not be enough to reconcile your concerns.

You're early in your career and you might find a better niche. Don't put yourself in situations where you might emotionally burn out early. Good luck to you!

Da_Milk_of_Amnesia, MSN · Jun 21, 2014

You need to detach yourself from the situation. Some people are better at it than others. Being detached doesn't mean being heartless or cold, it just means keeping your emotions and feelings out of it. I've dealt with many situations as you describe, I've had 1 dude actually walk out under is own power and be fully neurologically intact. Most of your ECMO PTs will be veggies. The rest were sent to the 'head-shed' or terminally decannulated. I've actually had one patients heart literally stop while on VA ECMO...talk about a ethical dilemma. Either way, I keep my emotions out of it. I may feel bad or empathize with there people but it's their decision, not mine. I've flat out told people that their family member is brain dead, like it or not, once it's been told to them by the MDs I have no problem letting them know again. I had a young girl whose mom was is a persistent vegetative state and flat out asked what she was told about her condition and prognosis. I eventually asked her if this is how her mother would want to spend the rest of her life, she'll never talk, walk or do anything but lay in a hospital bed. Was I mean? No..Blunt and honest? You bet. At the end of the day, it's not my problem or my decision. I'm going to go home and sleep just fine at the end of my 12 hours, these people will have to deal with their decisions for a life time. Over the years I've just learned to distance myself mentally from stuff like that. If that makes me a cold hearted or bad nurse then fine.

Ruby Vee, BSN · Jun 21, 2014

If you're having ethical issues with ECMO patients, I'm sure there are plenty of other nurses on your unit who would love to take care of such a complex patient. Simply make your wishes known to the charge nurses.

I cannot disagree with you on the futility of ECMO under most circumstances. Either you can find a way to deal with your emotions and your moral dilemma or you cannot. It may help to distance yourself from the situation a bit. It may also help to realize that even if you disagree with the decisions these families are making, it is their decision to make. As horrible a decision as it sometimes is, it's theirs, not yours.

As I get older and as health care costs are spiraling out of control, I think more and more that we're spending too much money to keep some terminally ill folks alive for a few more days. Money that could instead be spent providing basic health care for every adult in the county.

The Crushing Cost of Health Care - WSJ

nursingreimagined · Jun 23, 2014

I have been an ECMO Specialist for several years and most recently an ECMO Coordinator. I provide bedside PICU care and work as a night Supervisor. The thing I tell people about ECMO is that when a family is offered ECMO as an option for their child, the other option is death. If you can put it in perspective, if you have a 40% survival rate off ECMO, that means that you lost 60% of qualified patients instead of 100%. It is up to the family whether or not they want to try ECMO, and most times they do, and you can't control the outcome or any long term consequences of their decision but you can take some solace in knowing that the family can have some peace knowing they tried everything they could to save their loved one. If they didn't try, they would always wonder if ECMO could have saved them.

That being said, I agree with previous posters that if the ethical dilemma is too great for you or if you feel like you're getting burned out and in the wrong area of nursing, it may be a good idea to try something else.

Best of luck to you!! :)

Ruby Vee, BSN · Jun 23, 2014

I have been an ECMO Specialist for several years and most recently an ECMO Coordinator. I provide bedside PICU care and work as a night Supervisor. The thing I tell people about ECMO is that when a family is offered ECMO as an option for their child, the other option is death. If you can put it in perspective, if you have a 40% survival rate off ECMO, that means that you lost 60% of qualified patients instead of 100%. It is up to the family whether or not they want to try ECMO, and most times they do, and you can't control the outcome or any long term consequences of their decision but you can take some solace in knowing that the family can have some peace knowing they tried everything they could to save their loved one. If they didn't try, they would always wonder if ECMO could have saved them.
That being said, I agree with previous posters that if the ethical dilemma is too great for you or if you feel like you're getting burned out and in the wrong area of nursing, it may be a good idea to try something else.
Best of luck to you!! :)

I think the ethics of the situation may be different if you're offering ECMO for a child as opposed to a 66 year old with multiple co-morbidities. In my mind, they are, anyway. I've seen very few successful (patient able to leave the hospital, walking, talking and able to balance their own checkbook) outcomes among adults.

nursingreimagined · Jun 23, 2014

I agree. There is definitely a difference between pediatric and adult ECMO and I have managed both. Co-morbidities can certainly make a difference but that goes back to the core of ECMO, yes? It is not a cure but merely a supportive therapy while the body recovers. If a patient has medical problems that make recovery doubtful, then ECMO shouldn't be employed. (That happens in pediatrics as well and doctors frequently will try more heroic efforts against futility in children...no fun cannulating a corpse) Unfortunately we're not the ones who get to make that decision but merely get to provide the support if it is ordered.

MunoRN, RN · Jun 23, 2014

I'd argue that if you have the ability to suppress your ethical/moral concerns on a regular basis then you shouldn't be taking these patients.

The use of ECMO in patients for whom there is little potential for meaningful recovery varies widely. I've worked in a facility where it was overused, and that raises concerns for nurses and other caregivers, which is a good thing. My current facility uses ECMO much more judiciously; they don't all have a good outcome, but they all have at least a small potential for a good outcome. If it wasn't for a healthy concern about unethical use of ECMO by various caregivers, my current facility wouldn't have found this balance.

tcvnurse, BSN, RN · Jun 23, 2014

I have found in our unit that the younger a patient is--and we do adults only, no pediatrics for me!-- the better their shot is. Seen a 27 year old female live from being on VA ECMO for 3 weeks. Just came back to visit us-- doing GREAT. Last week we saved someone that would have died from a MVA, that patient is awake and talking to his family now. Another younger adult last fall who beat his fungal pneumonia and has the ECMO scars to prove it.

However. Have seen an awful lot of futile attempts to save elderly people with ECMO. It's a therapy we offer, the doctors explain everything to the families, so if that's my patient I do my job the best I can.

Maybe just ask for a different assignment, OP? Our charge RN's always ask for volunteers for the ECMOs or else assign them a preceptor-orientee combo.