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Ethics and End of LIfe

Research Snapshot Theater: Ethics and End of Life, Adult I

(358) Discontinuation of ECMO in a Patient Bridged to Nowhere: A Case Report on End-of-Life Care

Monday, February 24, 2025
10:15am – 11:15am Eastern Time
Location: Connections Central - RST 01

    First Author(s)

  • YUKI MUNEKATA, M.D.

    Sapporo-shi, Hokkaido, JPN

    • Co-Author(s)

  • kunihiko maekawa, M.D. (he/him/his)

    Assistant Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University
    Sapporo, United States

  • mm

    mone murashita, M.D.

    Senior Resident
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • JK

    Jun Kato, M.D.

    Senior Resident
    Department of Emergency Medicine, Sunagawa City Medical Center, United States

  • SF

    Shoki Fukui, M.D.

    Senior Resident
    Department of Emergency and Critical Care Medicine, Sapporo City General Hospital, United States

  • mt

    masaki takahashi, M.D.

    Attending Doctor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • YT

    Yuki Takahashi, M.D.

    Attending Doctor
    Department of Emergency Medicine, Sunagawa City Medical Center, United States

  • tt

    takumi tsuchida, M.D./Ph.D.

    Attending Doctor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • am

    asumi mizugaki, M.D./Ph.D.

    Attending Doctor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • ST

    Shuhei Takauji, M.D./Ph.D.

    Attending Doctor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • mh

    mariko hayamizu, M.D./Ph.D.

    Specially Appointed Assistant Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • yh

    yoshinori honma, M.D.

    Specially Appointed Assistant Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • ts

    tomoyo saito, M.D./Ph.D.

    Specially Appointed Assistant Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • tomonao yoshida, M.D.

    Japanese Society of Intensive Care Medicine
    sapporo, Hokkaido, JPN

  • kk

    kenichi katabami, M.D./Ph.D.

    Assistant Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • mh

    mineji hayakawa, M.D./Ph.D.

    Associate Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

  • TW

    Takeshi Wada, M.D./Ph.D.

    Professor
    Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, United States

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiopulmonary support during cardiac arrest (CA). ECMO has four potential goals: as a bridge to recovery, device, transplant, or decision. However, some patients may survive only with ongoing ECMO support without destination therapies, termed a bridge to nowhere (BTN). We encountered a case where BTN ECMO provided significant end-of-life care (EOLC) value to the patient and her family.

Description: A 65-year-old woman suffered an out-of-hospital CA due to myocardial infarction. On arrival, she was in CA refractory to noradrenaline but exhibited spontaneous breathing. VA-ECMO was administered. Following an emergency coronary angiogram and percutaneous coronary intervention, her neurological condition recovered despite 56 minutes of CA. However, her cardiac condition worsened, but an attempt to insert an Impella device failed due to narrow blood access. Age restrictions in Japan precluded a ventricular assist device or heart transplant, resulting in her placement on a BTN. After repeated discussions, she and her family decided to discontinue ECMO. She was weaned from the ventilator, and the tracheal tube was removed before discontinuation of ECMO. Thus, she was fully conscious and could spend her last moments with her family. She died on the 20th hospital day soon after discontinuation of ECMO. This case underscores the EOLC value of BTN ECMO in facilitating meaningful final moments with loved ones.

Discussion: Although a BTN generally should be avoided, such ECMO support may not be entirely negative. In our case, ECMO allowed the patient to have meaningful final moments with her family, which is crucial from an EOLC perspective. Furthermore, her extended survival with ECMO and discussions with healthcare providers helped her family prepare for her death. ECMO is often withdrawn due to refractory cardiopulmonary failure rather than neurologic injury. Our case suggests that early ECMO withdrawal should be reconsidered, especially when the patient’s neurological condition is preserved, as BTN ECMO can still contribute to qualified EOLC. Although ECMO is perceived as a bridge therapy, our case shows that BTN ECMO can hold significant value.