Concerns rise over costly emergency intervention — a ‘bridge to nowhere?’

ECMO-300x212Medical ethicists and patient advocates are raising concerns about a big, costly, and often unsuccessful procedure that “pumps blood out of the body, oxygenates it, and returns it to the body, keeping a person alive for days, weeks or months, even when their heart or lungs don’t work,” the Kaiser Health News Service reported.

Extracorporeal membrane oxygenation or ECMO (eck-moe) is considered an appropriate treatment for some patients on death’s door.

But hospitals, to maintain their competitive business standing, are battling to get the equipment and staff to provide this therapy, which costs on average half a million dollars per patient.  The number of hospitals that can do ECMO has increased from 108 in 2008 to 264 now, with the number of ECMO procedures tripling since 2008 to almost 7,000 in the last count in 2014.

Dr. Kenneth Prager, director of clinical ethics at Columbia University Irving Medical Center, cautioned KHN reporter Melissa Bailey that ECMO is creating “an entirely new paradigm … You have a heart that’s not working, yet the patient is not dead.”

As doctors learn more about ECMO, they have made advances in its use, including shrinking the size and increasing the portability of the oxygenating unit. Still, it is labor intensive and fraught with risk. Here’s how the respected UCSF medical center describes the intervention:

“Being placed on ECMO requires a surgical procedure but it is usually done in a patient’s room. The patient is sedated and given pain medication and an anti-coagulant to minimize blood clotting. A surgeon, assisted by an operating room team, inserts the ECMO catheters into either an artery or veins. An x-ray is then taken to ensure the tubes are in the right place. Usually a patient on the ECMO pump will also be on a ventilator, which helps the lungs to heal. While on ECMO, the patient will be monitored by specially trained nurses and respiratory therapists, as well as the surgeon and surgical team. Since you will be sedated and have a breathing tube in place, supplemental nutrition will be provided either intravenously, or through a nasal-gastric tube. Nutrition is delivered either intravenously, or through a nasal-gastric tube. While on ECMO, you may be given … medications including: heparin to prevent blood clots; antibiotics to prevent infections; sedatives to minimize movement and improve sleep; diuretics to help the kidneys get rid of fluids; electrolytes to maintain the proper balance of salts and sugars; and blood products to replace blood loss. Discontinuing ECMO requires a surgical procedure to remove the tubes. Multiple tests are usually done prior to the discontinuation of ECMO therapy to confirm that your heart and lungs are ready. Once the ECMO cannulas are removed, the vessels will need to be repaired. This can be done either at the bedside or in the operating room. The doctor will use small stitches to close the spot where the tubes were placed. You will be asleep and monitored for this process. Even though you are off the ECMO, you may still need to be on a ventilator.”

As Bailey describes it, for every patient hooked up on ECMO and benefiting from it, another patient dies. The procedure, to be blunt, is life sustaining but it is not meant per se to heal or fix patients’ conditions but to buy them time for their own bodies to repair themselves or so further procedures can be undertaken. As the article reported:

“ECMO is not designed to be a destination, but a bridge to somewhere – recovery, transplantation or an implanted heart device. But when patients are too sick to reach those goals, ECMO can become a ‘bridge to nowhere,’ leaving the patient in limbo, possibly even awake and alert, but with no chance of survival outside the intensive care unit. Medical teams and families can be fiercely divided over when to pull the plug.”

The life choices can get tougher still, Bailey found:

“Some ECMO patients have severe, irreversible brain damage, can’t participate in decision-making and bear no chance of making it out of the hospital alive. For them, ECMO represents “the most extreme form of medical futility,” Dr. Shunichi Nakagawa, a palliative care doctor at Columbia, argued in an article he and Prager co-wrote with a colleague in the journal Circulation. They argue that clinicians should have the authority to end or limit life support in such hopeless cases, even if the family objects. Whether they can do that depends on where they practice: Laws in states such as Idaho, Oklahoma, and New York make it difficult to withdraw life-sustaining treatment like ECMO without consent from patients or their families, said Thaddeus Mason Pope, director of the Health Law Institute at Mitchell Hamline School of Law in St. Paul, Minn. But in states like California, Texas, and Virginia, clinicians may withdraw ECMO without consent, he said.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become a greater ordeal due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which prove to be dangerous drugs.

When patients are injured or ill and require medical care, their doctors must provide them their fundamental right of informed consent. This means they are told clearly and fully all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom. Providing this crucial information can be a challenge, however, if patients fall into such poor shape that they lack the capacity to participate in appropriate ways in decisions about their treatment.

This underscores the importance for us all — while healthy, or relatively so — to consider working with our loved ones, doctors, lawyers, and financial advisers to ensure our wishes about our lives, especially near and at the end, get fully considered with the power of the advanced directive and other legal and medical planning tools. The advance directive is a form that you can get from groups like the AARP (the documents vary, state by state). Be sure that everyone who might need to see the directive in stressful, potentially emergency situations know where it’s at, including, possibly as an attachment to your electronic health records.

It’s not easy to learn more about the medical procedures like ECMO that may be undertaken in extreme circumstance to sustain life. Patients and families may wish to think carefully about these steps, including resuscitation orders and the optimism that may underlie them. For the elderly, and especially for those who already are sick and frail, the most common procedure of CPR (cardiopulmonary resuscitation) can have poor outcomes. If patients are revived and sustain for some time, they often may experience pain: CPR may not seem invasive, but it often breaks ribs and can leave bruised patients in discomfort (rib injuries are among the most challenging, because they can affect all manner of everyday activities, including breathing, coughing, laughing, and eating). If elderly patients respond to CPR, they often then may need intubation and the statistics on that procedure aren’t rosy.

It’s impossible, of course, to forecast with 100% certainty about outcomes of medical procedures, and this also applies to efforts to say if patients are end stage and terminal. Still, research shows that end-of-life care can be among the most costly in patients’ lives — expenses that may have been exaggerated, too. But a healthy, thoughtful individual might pause at the prospect of her loved ones saddled with sizable medical debt, especially for wildly expensive medical procedures with iffy prospects at best for patients.

ECMO experts say they are finding it vital to spend as much time as they can with patients and their loved ones, so they fully understand how the procedure works, its costs, risks, benefits, and mixed outcomes. That’s a good step, and here’s hoping in idealistic fashion that commercial considerations by doctors, hospitals, insurers, and medical device makers never enter the already freighted choices about this type of care.

Illustration credit: Courtesy, The Journal of Thoracic and Cardiovascular Surgery
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