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[Lancet Respir Med专家观点]: 何时应当讨论ECMO?
2019年09月20日 研究点评, 进展交流 暂无评论

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When is the right time to discuss ECMO?

William B Feldman, Steven P Keller

Lancet Respir Med Published:August 12, 2019 DOI:https://doi.org/10.1016/S2213-2600(19)30278-4

The rise of extracorporeal membrane oxygenation (ECMO) over the past decade as a support modality provides clinicians with a powerful new therapy to care for patients with advanced cardiopulmonary disease. The growing use of this technology has required careful attention to the ethical challenges that accompany its use, including the allocation of scarce resources, determining when a trial of ECMO support is unsuccessful, managing conscious patients on ECMO without a viable pathway to recovery or destination therapy, and determining the role of ethics consult services in addressing the concerns of patients and care providers. Even as these challenges are presented and examined in the academic literature, comparatively little attention has been paid to the way clinicians communicate about ECMO. How should we broach the possibility of ECMO with patients and families in the first place?

One method, which we have encountered at our hospital, is for intensivists to introduce ECMO to families just before consulting the ECMO service or, in some cases, to defer initial discussion to the consulting ECMO service. As a patient's respiratory function declines or circulatory shock worsens, the intensivist might choose to delay discussion of ECMO until after exhausting conventional measures. Introducing ECMO early in a patient's course might place an unnecessary emotional and cognitive burden on families when alternative, less invasive therapies might suffice. Moreover, even when ECMO is the only potentially life-saving therapy remaining for a patient, the patient might be ineligible for support depending on institutional criteria. Extracorporeal support, in this respect, is akin to surgery; after evaluation, the procedural team regularly declines to initiate ECMO, regardless of the patients' or surrogates' expressed preferences, because the attendant risks of this technology might outweigh anticipated benefits. ECMO is very different from standard resuscitation, where a code team, for the most part, attempts to resuscitate all who wish to be resuscitated—and indeed presumes that all, in fact, wish to be resuscitated unless specifically informed otherwise. In the case of ECMO, why offer false hope well in advance of determining whether this treatment will even be an option?

If deferring discussions to the day of ECMO initiation falls to one extreme in the debate about when to broach ECMO, then moving conversations to the day of hospital admission or even to an outpatient clinic visit falls to the other. In many ways, the current challenges faced in determining the appropriate timing and setting of ECMO conversations mirror the challenges that physicians faced as mechanical ventilation came into use. The invention of ventilators created a novel and invasive means of supporting patients with respiratory failure while laying the foundation for modern critical care medicine. Widespread use of mechanical ventilators in the mid-20th century gave birth to previously unnecessary, and once even inconceivable, discussions between patients and physicians. Both groups struggled to balance the risks and benefits of this new technology as the nascent field of critical care medicine honed new strategies for optimal patient selection and titration of support. Today, goals-of-care conversations that touch upon intubation and resuscitation are an important vehicle through which patients and physicians build relationships with one another and align medical care with patient values. Perhaps the rise of ECMO in the 21st century should likewise propel new modes of patient–physician communication focused on future contingencies rather than present emergencies.

In this vein, some have started calling for a new category of code status—do not ECMO (DNE)—to enable a more nuanced expression of preferences. Patients unwilling to receive ECMO support might wish to be DNE while still desiring conventional resuscitation and intubation. Those opposed to long-term mechanical ventilation might opt to be do not intubate (DNI) while accepting resuscitation and extracorporeal support. The use of ECMO for cardiopulmonary resuscitation, for which the time window for intervention is particularly narrow, provides further impetus for early conversations about extracorporeal support.

Yet more universal conversations about ECMO would place a substantial burden on physicians. The time required to explain ECMO, whether as an inpatient provider trying to complete an already-crowded admission checklist or a primary-care doctor with 15 min to navigate a visit, could detract from patient care. Providers, moreover, might be uncomfortable explaining this new technology. Despite the rapid increase in its use, ECMO remains a highly subspecialised modality to which internists have limited exposure. Physicians might give incomplete or inaccurate information leading to documentation of preferences deviating from patient values. The complexity of ECMO itself might overwhelm patients and reduce their willingness to delve into more germane questions about their health-care goals.

Although incorporating ECMO into every code conversation is impractical for physicians, waiting until the day of ECMO consultation can be paralysing for patients and families. ECMO practitioners should work with outpatient providers caring for patients at the end-of-life—in oncology, cardiology, palliative care, pulmonology, geriatrics, and elsewhere—to develop strategies and, ideally, validated conversation guides to discuss ECMO with selected patients. When patients present to the hospital with hypoxaemia, admitting medical teams should become more comfortable introducing ECMO, just as they are comfortable explaining the basics of mechanical ventilation. More training in communication about ECMO will be critical to instil this comfort. Perhaps most importantly, those who work in intensive care units, who meet patients already requiring advanced respiratory support, must become skilled at describing the mechanics of ECMO, framing the practical process of ECMO consultation or transfer to ECMO centres, and answering questions about the role of ECMO in the patient's broader care plan.

We anticipate that this challenge will become more urgent as new methods of extracorporeal support, such as extracorporeal carbon dioxide removal (ECCO2R), which allow physicians to treat hypercapnic respiratory failure on low-flow circuits similar to those of dialysis, are adopted. These modes of carbon dioxide removal in DNI patients with chronic obstructive pulmonary disease might be scarcely different from haemodialysis in DNI patients with chronic kidney disease. As these technologies move from the laboratory to the bedside, physicians must be prepared to engage with the new therapies and their patients to determine optimal courses of care. Our hope is that communication about extracorporeal support will mature this century in the way that communication about mechanical ventilation matured in the last, and that improved communication will ensure that patients receive care that aligns with their needs and values.

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