ECMO Ethics

[Kettek53]

I'm really struggling lately at work. I have now been in the CVICU for 1.5 years after working in the MICU for 1.5 years, and initially I loved it. I loved recovery hearts straight from surgery, and managing severe heart failure patients. It offered me a new set of challenges that my previous jobs hadn't. I really enjoy the quick progression that is associated with heart surgery (most of the time). Now that I have gained more experience on the unit, and am beginning to feel more comfortable in my role, I have began caring for ECMO patients

it is since taking on this new patient population that I have really been finding myself struggling morally, and I don't know what my best personal course of action should be. We mostly do VA ECMO, and these patient arrive to us essentially dead. They are resuscitated for as long as 1.5 hours with a Lucas device, and then placed on ECMO once ROSC is achieved. Sometimes the patients need to be on ECMO for as long as 2-3 weeks, at which point, regardless of level of stability (sometimes the patients are on CRRT for this whole time as well), they are transition to an LVAD. The patient is usually trached and peg tube is placed after the VAD, and they wake up.

I fear for the patients overall quality of life once they leave our unit. It is not uncommon for this patient population to lose a limb, or suffer trauma to there femoral arteries from the ECMO placement. I find it to be increasingly difficult for me to care for these patients. I feel cynical over the situation, and that family doesn't really understand what all of this new equipment entails. My hands are tied as a bedside RN, because I am limited in what I can share with family.

I am am wondering, all you ECMO nurses out there, do you involve ethics committee in all of your cases? Or just certain ones? I find our ECMO docs to be dreamers, and statistic driven in their treatment options, that they don't take a step back and think about the fact that this is a human life we are dealing with, not just another percentage point.

Maybe be I am too driven by fate and chance to be an effective bedside RN for ECMO patients. I really love the complexity of the medical aspect of the patient, but it am having to force myself to not think of them as people in order to not feel heartbroken over the numerous lifelong ailments we are potentially causing them.

I am ready to quit. I need feedback people.

[Biffbradford]

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.

You would never see these patients in a CVICU. There are miracle stories about ECMO all over Youtube, but even if you had one of them while on ECMO, you'd never know how they did in the long run. "How's Mr. Smith doing?" "Oh, fine". HIPPA you know. I've done my ECMO time in CVICU. Been there, done that, but no more thanks, only to be seen on my resume' from now on.

[tcvnurse, BSN, RN]

What do you mean she would never see those patients in a CVICU? I see them in mine although we call it TCV instead of CV. Ruby and other posters have commented similarly. Perhaps I am misunderstanding your meaning though....

[Biffbradford]

MVAs? Nope. Never. THey go to a different hospital entirely. Fungal Pneumonia? Only if they caught it after open heart surgery, and OUR surgeons would never let THAT happen! If they aren't there for thoracic surgery, they are out the door ASAP. If you've got all that other crap taking up your beds, then how are you going to get all your cases in?

[JeanOfAllTraits]

At our hospital pt typically come from the other ICUs, mainly MICU, very rarely SICU and Neuro Crit, to the CVICU for ECMO. So a fungal PNA in a young guy would be totally reasonable to have on the unit. We were actually full of 20 something influenza/PNA with HX of asthma on ECMO this winter. Several did well enough to come off and do well or get lungs and go through the transplant process.

[ghillbert, MSN, NP]

I specialize in mechanical circulatory support. It's a tough arena. There are a lot of people that we "save" who end up dying later on after a miserable long hospital stay. Then again there are young postpartum women with H1N1 that survived fine and come back to visit. There are a lot of VAD patients that are implanted as destination therapy - indeed, "most" would not be an exaggeration - who most people would say are unsalvageable (or should be). I can't agree, having seen 75 year old sickies who end up surviving to dance with their wife on their 50th anniversary, or see their grandchildren born. Sure we're not offering eternal life and I don't think anyone thinks we are. ECMO and VAD are for end stage heart failure or imminently life-threatening conditions; when your other choice is dead, it's a pretty easy decision. The saves make up for the ugly cases to me, but if they don't to you, pick another specialty. It's certainly not for everyone and it is wearying at times.

PS: And no, I certainly don't think either the patient or their family are aware of what they are getting into. Particularly for destination therapy VADs I find the idea of "informed consent" is flawed - either they are in a low flow state with minimal cerebral perfusion and/or they were just told they will die soon; either way, the only answer is "yes please, Doctor" - and they all say later they had no idea what they got themselves into. Most would make the same choice because they were out of choices, but they definitely didn't bargain for what they got.

[adventure_rn, MSN, NP]

Sure we're not offering eternal life and I don't think anyone thinks we are. ECMO and VAD are for end stage heart failure or imminently life-threatening conditions; when your other choice is dead, it's a pretty easy decision...

...PS: And no, I certainly don't think either the patient or their family are aware of what they are getting into. Particularly for destination therapy VADs I find the idea of "informed consent" is flawed - either they are in a low flow state with minimal cerebral perfusion and/or they were just told they will die soon; either way, the only answer is "yes please, Doctor" - and they all say later they had no idea what they got themselves into. Most would make the same choice because they were out of choices, but they definitely didn't bargain for what they got.

That kind of the OP's whole point though, right? Families (and patients) who don't understand the gravity of their choices may cause their loved ones to suffer a long, drawn out, miserable death with no quality of life rather than choosing a death that's dignified and minimizes suffering. I agree with PP that it's a symptom of our culture, but I definitely understand the ethical dilemma. Even if the choice is 'possibility of life vs. certain death,' we might amend this dyad to 'significant likelihood of prolonged pain, suffering, and loss of dignity vs. dignified, albeit certain, death.' As I believe the OP may be trying to say, with those more realistic expectations, perhaps some people would choose death.