The Role of Palliative Care Consultation in Withdrawal of Veno-Arterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

Abstract

To evaluate the clinical characteristics of patients withdrawn from veno-arterial extracorporeal membrane oxygenation support (VA-ECMO), as well as the role of palliative care (PC) consultation in the decision to withdraw VA-ECMO. We retrospectively reviewed the electronic medical records of adult patients with cardiogenic shock treated with VA-ECMO at our institution between March 1, 2007 and May 31, 2019 to determine those who died after VA-ECMO was withdrawn. Patients were excluded if they survived less than 2 hours on VA-ECMO, died more than 72 hours after withdrawal, or were diagnosed with brain death prior to withdrawal. Of 643 Patients who received VA-ECMO, 127 patients (19.8%) were included. The etiology for VA-ECMO initiation included acute decompensated heart failure (11.8%), acute myocardial infarction (22.0%), extracorporeal cardiopulmonary resuscitation (4.7%), post-cardiotomy shock (34.6%), and others (26.8%). Mean time on VA-ECMO was 6.1 days, and most patients had other forms of life support, including renal replacement therapy (64.6%), mechanical ventilation (97.6%), intra-aortic balloon pump or Impella (47.2%), and AICD or pacemaker (16.5%). After 2013, 43 patients (44.8%) had a PC consult with a mean of 6.4 days from initial consultation to withdrawal. Only 1 patient had capacity to request withdrawal, and 1 patient had no surrogate requiring a legal guardian to be designated. At the time of withdrawal, 31 (24.4%) had clinical or radiologic evidence of anoxic brain injury, and this was associated with number of life support measures, length of time on VA-ECMO, and number of PC visits (Wilks lambda 0.5549, DF 4,71, p = 0.006). The length of time on VA-ECMO correlated with increased number of PC visits (r=0.525, p=0.001). Presence of anoxic brain injury was associated with decreased number of PC visits (t=3.02, p=0.003). Most patients withdrawn from VA-ECMO did not have capacity to determine their end of life care. Number of PC visits may be a surrogate marker of the complexity of the decision to withdraw. The longer the time on VA-ECMO, the greater the number of PC visits patients received. Further, the presence of anoxic brain injury was associated with fewer PC visits, which may indicate a less controversial decision to withdraw in patients with poor neurological prognosis.