Discontinuing ECMO Support–An Interdisciplinary Approach

Abstract

Extracorporeal membrane oxygenation (ECMO) is a temporary means of providing mechanical support in patients with severe respiratory or cardiac failure. Patients who are on ECMO also tend to be on multiple other life-sustaining modalities such as renal replacement therapy (RRT), ventilator support, vasopressors and anticoagulation. When a decision is made to discontinue ECMO support, knowing how and when to discontinue the other multiple life-sustaining measures can be challenging. Palliative providers may not be familiar with the ECMO circuit and the surgical intensive care unit (SICU) and surgical teams may not be comfortable with withdrawing of life support. We present a case where an interdisciplinary approach was crucial in ensuring that the patient's comfort and dignity were preserved during the process of withdrawing multiple life-sustaining modalities. CH was a 34-year-old woman with a history of left ventricle dysfunction and thrombus. She presented to the hospital with chest pain and was found to have an ST elevation myocardial infarction. She underwent catheterization and three-vessel stent placement. This was complicated by ventricular fibrillation and cardiogenic shock, requiring intubation, intra-aortic balloon pump, multiple vasopressors, and ultimately ECMO. Her course was complicated by abdominal compartment syndrome, retroperitoneal hematomas, and cerebral infarcts. Our palliative consult service was consulted to facilitate goals of care discussions and after several family meetings, the family decided to withdraw life-sustaining measures. Our team worked closely with the surgical team, SICU team, bedside nursing, respiratory therapist and ECMO perfusionist to formulate a timeline of discontinuing the ECMO support, RRT, vasopressors, anticoagulation and ventilator support, along with recommendations for symptom management for end of life care. We have found that using this interdisciplinary approach not only ensures good symptom management and a smoother transition to comfort care, but also provides clarity and understanding for all members of the treatment team.