Ethics of ECMO Panel discussion presentation 2024.pptx

Ethical issues

1. Ethics in ECMO Panelists : Dr Suneel Pooboni Dr Venkat Goyal Dr Pranay Oza Vivek GUpta Dr Dipanjan Chatterjee Dr Nandkishore Moderator: Apran Chakraborthy

2. No disclosures / conflict of interest

3. Goals Patient best interest Autonomy Informed consent Shared Decision making Surrogate decision making End of life care/ Advance directives

4. Principles of Ethics Beneficence : Good of patient comes first Non- Maleficence : First Do No Harm Autonomy : Patients have right to choose / refuse treatment Justice : Scarce resources should be distributed fairly

5. Ethical principle & challenges during ECMO Limited evidences: Challenging Beneficence Expensive: Challenges Justice Addresses the definition of death: Challenges the integrity Mostly demand sedation: Challenges Autonomy Not a treatment: Challenges Non-maleficence

6. Current issues DNR but ECMO acceptable ? CPR acceptable but not ECMO Do not Intubate but ECCO2R acceptable Do not ECMO orders What does DNR means on VA ECMO ? Moral Distress

7. CASE 1 48 year/ male, post-renal transplant with COVID ARDS, on ventilator PCO2 > 140, Ph 6.8, PO2 44 Norad / Vasopressin/ Adrenaline Retrieval call ..100 km distance One episode of bradycardia , responded with adrenaline purge On arrival, pupils B/L dilated and not reacting

8. CASE 2 11 month old , Septic myocarditis with pneumonia, 21 days of ECMO CFTR gene came positive Need to change the oxygenator Parents does not want to continue further

9. CASE 3 50 year old Male, severe COVID ARDS with PF ratio 0.5 after two episodes of proning and 3 weeks of HFNO Shifted to our hospital Only one ECMO console is free Other all machines are occupied with least chance for getting free for next few days At the same time, 22 year old Amlodipine poisioning came to emergency after 18 hours of ingestion in shock

10. CASE 4 62 year old, extensive covid fibrosis in CT, on VV ECMO for 140 days Family counseled for lung transplant since 2 months, but they denied repeatedly He is awake, alert and communicating Repeated attempts failed for weaning Now landed in septic shock Family wants to escalate to VA support or whatever more can be done

11. Challenges The patient : Being aware of fact of impending death can be distressing and suffering The family: DNE/ Withdrawal decisions are emotionally challenging for them for such pt Health care providers : Moral distress and close ties with families for prolonged stay

12. CASE 5 29 years, Male, 142 Kg Severe Viral ARDS, Non-responder of proning on high mechanical ventilation Shifted to our hospital Rescued on VV ECMO Lungs are white even after 21 days Family belongs to a village and were arranging money from village & relatives they have nothing to continue treatment

13. Hospital support Minimizing investigations Need for Crowd funding Consortium of ECMO survivors and their families Counselling is a continuous process All team members should take a single voice

14. Case 6 65/M patient was brought in ED with cardiac arrest As per relative he had chest pain and just at the gate of ED he was conscious The first identified rhythm was asystole Almost 20 mts had passed with high quality CPR with twicel VF which was defibrillated… CPR in progress Relative are aware about ECMO, since one family member survived on VA ECMO due to celphos poisoning with few minute CPR prior to VA ECMO