scholarly journals Ethics in extracorporeal life support: a narrative review

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Alexandra Schou ◽  
Jesper Mølgaard ◽  
Lars Willy Andersen ◽  
Søren Holm ◽  
Marc Sørensen
Keyword(s):  
Decision Making ◽  
Literature Search ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Modern Medicine ◽  
Narrative Synthesis ◽  
Shared Decision ◽  
Ethical Challenges ◽  
Allocation Decision ◽  
Comprehensive Literature Search

Abstract During 50 years of extracorporeal life support (ECLS), this highly invasive technology has left a considerable imprint on modern medicine, and it still confronts researchers, clinicians and policymakers with multifarious ethical challenges. After half a century of academic discussion about the ethics of ECLS, it seems appropriate to review the state of the argument and the trends in it. Through a comprehensive literature search on PubMed, we identified three ethical discourses: (1) trials and evidence accompanying the use of ECLS, (2) ECLS allocation, decision-making and limiting care, and (3) death on ECLS and ECLS in organ donation. All included articles were carefully reviewed, arguments extracted and grouped into the three discourses. This article provides a narrative synthesis of these arguments, evaluates the opportunities for mediation and substantiates the necessity of a shared decision-making approach at the limits of medical care.

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

2021 ◽  
Vol 10 (3) ◽  
pp. 383
Author(s):  
Jorik Simons ◽  
Martje Suverein ◽  
Walther van Mook ◽  
Kadir Caliskan ◽  
Osama Soliman ◽  
...  
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Shared Decision Making ◽  
Mechanical Circulatory Support ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Circulatory Support ◽  
High Morbidity ◽  
Shared Decision ◽  
Starting Point

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.

Interventions for Shared Decision-Making About Life Support in the Intensive Care Unit: A Systematic Review

2012 ◽  
Vol 10 (1) ◽  
pp. 3-16 ◽  
Author(s):  
Jennifer Kryworuchko ◽  
Elina Hill ◽  
Mary Ann Murray ◽  
Dawn Stacey ◽  
Dean A. Fergusson
Keyword(s):  
Systematic Review ◽  
Intensive Care Unit ◽  
Decision Making ◽  
Intensive Care ◽  
Shared Decision Making ◽  
Life Support ◽  
Shared Decision

scholarly journals ECCO2R as a bridge to a decision in type II respiratory failure

2019 ◽  
Vol 26 (1) ◽  
pp. 101-106
Author(s):  
Lina Grauslytė ◽  
Gonzalo De La Cerda ◽  
Tomas Jovaiša
Keyword(s):  
Decision Making ◽  
Case Report ◽  
Respiratory Failure ◽  
End Of Life ◽  
Lung Transplant ◽  
Life Support ◽  
Support Systems ◽  
Extracorporeal Life Support ◽  
Life Support Systems ◽  
End Of Life Decisions

Introduction. End-of-life decisions are often time consuming and difficult for everyone involved. In some of these cases extracorporeal life support systems could potentially be used not only as a bridge to treatment but as a tool to buy time to allow patient’s participation in decision making and to avoid further futile invasive procedures. Case report. A previously healthy 53-year-old female patient presented with respiratory failure of unknown cause. In the course of treatment her condition was deemed irreversible and the only option for any chance of long-term survival was a lung transplant. During this whole time the patient’s condition was managed with extracorporeal carbon dioxide removal system (ECCO2R). She remained compos mentis and expressed the wish to stop all the treatment as the option of lung transplant was not acceptable to her. Treatment was withdrawn and she passed away. Discussion. In cases of end-of-life decisions, time can play an essential role. Even though extracorporeal life support systems have been conceptualised to be a bridge to treatment, they could be beneficial in a situation when time is needed to make a decision. ECCO2R has been used as a treatment method in different settings, however, in this case it served as a tool to maintain the patient alive and conscious for a sufficient time for her to participate in decision making. Conclusions. Our case report demonstrated that ECCO2R could serve as a bridge to decision in situations when time is limited and the decisions that need to be made are difficult.

scholarly journals Shared decision making in high-grade glioma patients—a systematic review

2020 ◽  
Vol 7 (6) ◽  
pp. 589-598
Author(s):  
Helle Sorensen von Essen ◽  
Karin Piil ◽  
Karina Dahl Steffensen ◽  
Frantz Rom Poulsen
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
High Grade Glioma ◽  
Well Being ◽  
Treatment Decisions ◽  
Sufficient Information ◽  
Narrative Synthesis ◽  
High Grade ◽  
Shared Decision ◽  
Inclusion Criteria

Abstract Background Shared decision making (SDM) has proven to be a valuable approach in different patient populations when treatment decisions are called for. Along the disease trajectory of high-grade glioma (HGG), patients are presented with a series of treatment decisions. At the same time, HGG patients often experience cognitive deterioration and reduced decision-making capacity. This study aimed to review the current knowledge about shared decision making from the perspective of the HGG patient. Methods Systematic searches were performed in MEDLINE, CINAHL, PsycINFO, and EMBASE. Studies were reviewed against the inclusion criteria and assessed for methodological quality. Descriptive data from the included studies were extracted and a narrative synthesis of the findings was performed. Results The searches resulted in 5051 original records. Four studies involving 178 HGG patients fulfilled the inclusion criteria. The narrative synthesis revealed that most HGG patients in the included studies appreciated an SDM approach and that sufficient information and involvement increased patients’ emotional well-being. The use of a patient decision aid showed the potential to increase knowledge, decrease uncertainty, and affect the treatment decision making of HGG patients. Conclusion The results indicate that many HGG patients prefer an SDM approach and that SDM can lead patients toward improved emotional well-being. The evidence is weak, however, and firm conclusions and practice guidelines concerning SDM in HGG patients cannot be made. Future research is warranted to improve decision support for HGG patients.

scholarly journals Ethical Issues in Dysphagia Management

2020 ◽  
Vol 41 (03) ◽  
pp. 257-265
Author(s):  
Paula Leslie ◽  
Dominika Lisiecka
Keyword(s):  
Decision Making ◽  
Family Caregivers ◽  
Clinical Judgment ◽  
Information Disclosure ◽  
Ethical Issues ◽  
Shared Decision ◽  
Ethical Reflection ◽  
Ethical Challenges ◽  
Swallowing Problems

AbstractDysphagia management is complex and requires balancing individuals' preferences, quality of life, and medical consequences. Ethical challenges are not uncommon given the complexity of dysphagia. Professionals must engage in ethical reflection and shared decision-making when managing dysphagia. Recognizing one's own presuppositions and beliefs may be fundamental to ensuring an ethical approach. The goal of this article is to apply principles of ethics using hypothetical case studies of dysphagia. To this end, we will describe the challenges of working with the disorder of dysphagia; the influence of culture on decision-making about eating and feeding; the importance of information disclosure and respect for individuals' refusal of recommendations; and the interplay of ethical reflection, evidence, and clinical judgment when making complex dysphagia management decisions. These concepts should be kept in mind to ensure compassionate and competent care of the person with eating, drinking, or swallowing problems and their family caregivers.

Extracorporeal life support

2020 ◽  
pp. 167-178
Author(s):  
Ryan P. Barbaro ◽  
Gail Annich ◽  
Roxanne Kirsch
Keyword(s):  
Decision Making ◽  
Life Support ◽  
Ethical Decision Making ◽  
Extracorporeal Life Support ◽  
Early Mobilization ◽  
Bleeding Complications ◽  
Circulatory Support ◽  
Anticoagulation Management ◽  
Ventricular Assist ◽  
Severe Respiratory Infection

Using the narrative about a child with severe respiratory infection and septic shock, this chapter illustrates important learning points around both veno-arterial and veno-venous extracorporeal life support (ECLS) in children. Several important considerations such as patient selection, anticoagulation, management of bleeding complications, and respiratory rehabilitation on ECLS are discussed. The chapter includes a brief discussion of other forms of mechanical circulatory support (e.g. ventricular assist device) and early mobilization while on ECLS. The chapter highlights difficulties with prognostication, ethical decision-making dilemmas in patients on longer-term ECLS support, and provides a useful framework for decision-making.

Ethical considerations for post-cardiotomy extracorporeal membrane oxygenation

2012 ◽  
Vol 22 (6) ◽  
pp. 780-786 ◽  
Author(s):  
Constantine Mavroudis ◽  
Constantine D. Mavroudis ◽  
Jeanette Green ◽  
Robert M. Sade ◽  
Jeffrey P. Jacobs ◽  
...  
Keyword(s):  
Decision Making ◽  
Extracorporeal Membrane Oxygenation ◽  
Life Support ◽  
Selection Process ◽  
Extracorporeal Life Support ◽  
Best Interests ◽  
Membrane Oxygenation ◽  
Open Heart Procedure ◽  
The Right ◽  
Left Heart Syndrome

AbstractSignificant advances have been made in extracorporeal life support, which has resulted in the increased use of post-cardiotomy extracorporeal membrane oxygenation. Retrospective studies have contributed to the ongoing evolution of selection criteria for post-cardiotomy extracorporeal membrane oxygenation. Current indications include failure to wean from cardiopulmonary bypass, haemodynamic collapse, pulmonary hypertension, post-repair of hypoplastic left heart syndrome, or need for bridge to transplantation. Short- and mid-term results are improving. Ethical concerns still attend the process, however. Moral risks related to post-cardiotomy extracorporeal membrane oxygenation may be encountered before, during, and after the open heart procedure. At each stage of the decision-making process, moral risks are encountered by many factors that may result in decisions that may be contrary to the best interests of the patient, parents, or use of shared societal resources. These moral risks centre around the selection process, informed consent, decision making in the operating room, and post-operative maintenance of extracorporeal membrane oxygenation. Consideration of such risks is affected by questions of haemodynamic stability, haematologic compromise, neurologic status, and family concerns. We conclude that thorough understanding of the relevant scientific literature, heightened awareness of moral risks, and incorporation of ethical tenets in clinical deliberation will guide the clinician to do the right thing.

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