Nurses Explore Ethical Challenges Related to Patients Receiving ECMO Therapy

For patients in severe circulatory or respiratory distress, extracorporeal membrane oxygenation (ECMO) can be a lifesaving bridge to recovery or definitive treatment, including device or organ transplantation. The increasing availability of the sophisticated therapy, however, has prompted a growing number of ethical questions surrounding its potential rewards and sobering risks.

For nurses on the front line, caring for a dying patient on ECMO can be both clinically and morally challenging — particularly when managing discordance between the patient’s family members or healthcare surrogates. Furthermore, the complexity and lifesaving nature of ECMO can sometimes make it difficult to achieve true informed consent, says Georgina Morley, PhD, MSc, RN, HEC-C, Director of Cleveland Clinic’s Nursing Ethics Program.

Adopting an ethical framework

To manage such uncertainties, Cleveland Clinic nurse specialists are providing education on the Four-Box method, a common approach to working through ethical problems. Developed and described by Jonsen et al., the method is a case-based approach to ethical decision-making that helps providers organize and analyze relevant information about a clinical dilemma.¹

“The stakes are quite high anytime ECMO is considered, so families — and sometimes the patients themselves — are under an enormous amount of pressure to make the ‘right’ decision and make it quickly,” Morley explains. “In many cases, the patient is too unstable to provide informed consent, so clinicians must work closely with each other and the patient’s healthcare surrogates to determine the best course of action. When considering high-risk treatments like ECMO, the Four-Box method can be incredibly effective for illuminating the clinical and personal factors that matter most.”

The method, she explains, is based on four categories (i.e., boxes) that each hold the same weight in the deliberation process:
• Medical indications: the patient’s medical problems, disease process and prognosis
• Patient preferences: their goals, desires and ability to speak for themselves
• Quality of life: the patient’s ability to enjoy themselves and their current quality of life
• Contextual features: the patient’s family, finances, religious beliefs, ethnic background and relationships with care providers

The framework can be particularly valuable for helping nurses navigate ethical gray areas, says Rachael Jividen, DNP, APRNCNS, ACCNS-AG, CCRN-CSN CMC, Acute Care Clinical Nurse Specialist and Cleveland Clinic’s Adult ECMO Program Coordinator. She explains that such clarity can, in turn, enable nurses to have compassionate, informed conversations with families and other healthcare proxies.

“When managing a patient who lacks decision-making capacity, providers are left to rely on surrogate decision-makers and their own judgment to interpret a patient’s presumed preferences,” she says. “Although family members can help clinicians define goals of care, ECMO presents several more-nuanced questions that can be difficult to answer, including questions about what medical interventions the patient would accept and what a meaningful recovery looks like after separation from the ECMO circuit. The Four-Box method enables the entire care team to make decisions that respect the patient’s values yet limit nonbeneficial use of the therapy.”

Grappling with the unknown

Because patients managed in the intensive care unit are so sick when they arrive, clinicians can have difficulty imagining them as “whole, healthy people with full lives outside the hospital walls,” Morley says. “Your understanding of who they are and what makes them tick can be distorted by their current circumstances. Evaluating each case through an ethical lens, however, allows the care team to consider the perspectives of everyone involved to answer the most important question: What makes this patient’s life meaningful, and can ECMO help them regain it?”

Because nurses perform so many patient-facing functions, they are especially likely to experience moral distress when faced with morally ambiguous scenarios like those commonly seen with ECMO, Morley adds. To address these high-intensity concerns, Morley and Jividen round weekly in the Cardiovascular Intensive Care Units with Loni Adams, MSN, MBA, RN, CCRN-CSC-CMCCCTC. During these rounds, caregivers are encouraged to discuss any ethics questions they have and receive input about possible next steps.

“By rounding each week and through our nursing ethics education program, Moral Spaces, our hope is to create and sustain a network of clinicians who have expertise in exploring the ethical dilemmas surrounding ‘destination’ therapies like ECMO,” she explains. “Nurses may feel conflicted because, although they want to be hopeful and optimistic, many have witnessed bad outcomes for patients receiving the treatment. This dynamic can trap caregivers between the desire to be encouraging yet realistic. That’s where our ethicists come in. Using the Four-Box method, we aim to help nurses come to terms with the uncertainty that often accompanies these cases.”

The Four-Box method can also help nurse managers address moral dilemmas within their staff, Jividen adds. “After all, different nurses have different perspectives. Because our ultimate goal is to return the patient to their preferred quality of life — something that is not always possible — discussions about the long-term benefits of treatment can be complex and emotionally charged,” she explains.

Answers through education

To further increase nurses’ comfort with ethical decisions regarding ECMO therapy, Jividen uses Cleveland Clinic guidelines for extracorporeal life support and an ECMO hands-on competency checklist to train them on patient admissions, assessment of cannulation sites, ECMO circuit and oxygenator function, troubleshooting and intervention skills. A wet lab — a circuit primed with saline — is also used to review potential emergencies that caregivers might encounter.

“Arterial blood gases, venous blood gases, flow and other technical elements of ECMO need to be managed every day while also keeping an eye on the bigger picture,” Morley says. “In other words, can this treatment provide a meaningful life for the person in the hospital bed? By reinforcing both the clinical and ethical aspects of ECMO, we hope to improve nurses’ confidence not only in providing care but also in guiding patients and their families through their high-stakes journey.”

1. Jonsen A, Siegler M, Winslade W. Clinical ethics. Sixth ed. New York: McGraw-Hill, 2006.