Ethical Issue: The Withdrawal of ECMO

Ethical Dilemma

 Since the development of extracorporeal membrane oxygen (ECMO) as temporary life-support technology in the early 1970s, it had expanded as a therapy for numerous cardiopulmonary conditions (Williams & Dahnke, 2016). However, patients on ECMO life support are at high risk for death and conflicts sometimes arise that cause a blurry boundary regarding medical futile in continuation of treatment (Williams & Dahnke, 2016). The purpose of the paper is to discuss the ethical dilemma- withdrawal of ECMO which involves handling difficult situations and can lead to possible mitigation of ethical issues.

Legal Case

 An ethical dilemma is a difficult situation that requires decision making that is not necessarily right or wrong. The challenge is to make decisions where the outcome will satisfy all people involved- healthcare professionals, patients, and families. As a nurse, ethical dilemmas occur on a day-to-day basis with patients, families, providing treatments, and collaboration with healthcare professionals (Scott & Thompson, 2019). Healthcare professionals often will struggle between doing what is morally right and what is perceived futile care.

The withdrawal of ECMO has raised complex ethical issues of removal of life-sustaining therapies in general (Williams & Dahnke, 2016). For instance, The Wanglie case, which allows for the legal right of surrogates to decide to withdraw life-sustaining treatment, has been recognized across the United States. Mrs. Wanglie suffered from a fall in early December in 1989 and eventually developed respiratory problems and pneumonia (Angell, 1991). Mrs. Wanglie had become dependent on the medical ventilator and unable to wean off the ventilator (Angell, 1991). Later in May in 1990, she suffered from severe brain damage while hospitalized at Hennepin County Medical Center in Minneapolis, Minnesota. As a result,  doctors concluded that it was futile care and believed that it was not in her best interest to be kept alive (Angell, 1991). Although, her family wished to keep her remaining on the life support (Angell, 1991). Due to conflicting ethical issues, the hospital brought the case to the Hennepin County Court for the decision. The court favored the family’s decision to keep Mrs. Wanglie alive (Angell, 1991). Mrs. Wanglie died a few days later from multiple organ failure after the court’s decision (Angell, 1991).

Ethical Component

Ethical issues surrounding withdrawal of ECMO life sustaining therapy have brought up controversial opinions for decades. There are ethical issues involves in withdrawal of ECMO are: questions of autonomy and decision-making authority, determination of harm versus good provided by the treatment, uncertain concept of medical futility, issues of social justice related to the possible waste of medical resources, and moral distress on the part of those providing perceived futile care (Williams & Dahnke, 2016). When a patient lacks decision making ability, a surrogate will make decision on behalf of the patient. Often, conflicts arise when healthcare professional and surrogates disagree regarding life support treatment. For healthcare professionals, it raises ethical issue on ethical principles of nonmaleficence and beneficence (Williams & Dahnke, 2016). It conflicts when interpretation of harm versus good and perceived continued life through life support technology as futile care is a harm to patient (Williams & Dahnke, 2016). Third, the concept of medical futile are remain ambiguity (Williams & Dahnke, 2016). There is a lack of institutional policy regarding medial futility that dispute the legal treatment of withholding versus withdrawing (Williams & Dahnke, 2016). Despite the court ruling that there is no distinction between them and did not further define the medical futility (Williams & Dahnke, 2016). Next, the ethical issue of waste of medial resources on patients whose conditions are irreversible. From this perspective, continued allocation of resources on patients appear to be wasteful (Williams & Dahnke, 2016). The cost of futile care may put families against insurance payers and taxpayers (Williams & Dahnke, 2016). However, ethical issue arises when the social justice rules that patient should not received or  be denied distributive benefits in the healthcare (Williams & Dahnke, 2016). If patients are denied because of continued futile care of ECMO, standard of social justice would not be met (Williams & Dahnke, 2016). Lastly, moral distress cause psychological harm to healthcare professionals (Williams & Dahnke, 2016). With use of the ECMO technology, the life is prolonged and healthcare professionals perceived this as a harm and nonbeneficial to patient (Williams & Dahnke, 2016).

Moral Component

Moral distress occurs when there is a lack of authority to do what is perceived right. It brings psychological harm to health care professionals and families regarding the ambiguity concept of medical futile and various perspectives of EMCO treatment (Williams & Dahnke, 2016). The ambiguity concept of futility leads to ethical conflict and moral distress when ECMO providers on the healthcare team become frustrated and experience conflict between duty to provide requested treatment and the possibility of providing nonbeneficial and harmful interventions (Williams & Dahnke, 2016). Patients on ECMO life support are already at high risk for death results in conflicts regarding continuation treatment (Williams & Dahnke, 2016).

Legal Component

There are several laws that determine the legal limits actions of healthcare providers regarding withholding and withdrawing life-sustaining technology. Both Cruzan and Wanglie cases, surrogates indicate there is a legal difference between withholding and withdrawing life-sustaining treatment (Williams & Dahnke, 2016). According to the ruling of the U.S. Supreme Court, there is no legal distinction between withholding and withdrawing life-sustaining treatment (Williams & Dahnke, 2016).

When the Wanglie case won, surrogates have legal right to make decisions on the behalf of the patient even when the healthcare providers decide that life-sustaining treatment is no longer beneficial and would result in decompensation of organ systems (Angell, 1991). Therefore, surrogates in both cases believes that any continuation of life provided by life-sustaining treatment is beneficial to a patient (Williams & Dahnke, 2016).

Mitigate Legal Implications

The recommendation is to develop guidelines to mitigate ethical issues and legal implication involved in withdrawing ECMO life support for all parties involved will go a long way in mitigating problems that may arise (Williams & Dahnke, 2016). Ethics committee consultations and other organization support will assist to clarify explanations to support medial decisions for ECMO team and families concerning legal actions (Williams & Dahnke, 2016). Emphasis and support off the communications and informational role of the Advanced Practitionaer Nurse and nursing staff by organizing sessions for healthcare professionals to express concerns and opinions regarding futility care and stopping ECMO therapy (Williams & Dahnke, 2016). The participation of APN in ethics committee to represent nursing staff and provide a nurse perspective involves in life-sustaining technologies (Williams & Dahnke, 2016). According to Williams & Dahnke (2016), the stopping rules need to be further clarifying in ethical principles. As for autonomy issues, the policies of decision making should be more clarified (Williams & Dahnke, 2016). In nonmaleficence and beneficence, set up policies to ensure that the harm will be minimized and promote welfare of a patient (Williams & Dahnke, 2016). Organization develop stopping rules to address and prevent misuse of limited resources for patients on life-sustaining technologies (Williams & Dahnke, 2016). Lastly, the organization develop policies regarding futility care and lessen moral distress (Williams & Dahnke, 2016).

Link to the Case

The challenges of the life-sustaining technologies are linked to Wanglie case over the right to make decision on the behalf of the patient and create ethical issues in end-of-life decisions for all parties involved. Nurses are first and foremost advocate for the patient regarding treatments. When nurse note that the decision making is causing by uncertainty, lack of communication, and collaboration among all parties concerned then they find ways of handling decision making, establish healthcare professional collaboration, and educate surrogates to become more knowledge and comfortable about making decisions (Scott & Thompson, 2019).

In conclusion, when the ECMO treatment becomes a perceived as futile, there are a variety of ethical issues arise of autonomy and decision making authority, determination harm versus good provided by treatment, ambiguity concept of medical futility, waste medical resources, and moral distress impact on healthcare professionals providing perceived futile care (Williams & Dahnke, 2016). It is suggestion that organization develop guidelines to mitigate ethical issues and legal implication involved in withdrawing ECMO life support for all parties involved will mitigating problems that may arise in the future (Williams & Dahnke, 2016).

References

• Angell, M. (1991). The Case of Helga Wanglie. New England Journal of Medicine, 325(7), 511 512. doi: 10.1056/nejm199108153250712
• Scott, B. & Thompson, M. (2019). Transitioning from RN to MSN; Principles of professional role development. Springer Publishing Company, New York, NY.
• Williams, S. B. & Dahnke, M. D. (2016). Clarification and Mitigation of Ethical Problems Surrounding Withdrawal of Extracorporeal Membrane Oxygenation. Critical Care Nurse, 36(5), 56–65. doi: 10.4037/ccn2016504