A lifesaving medical technology puts some patients on a “bridge to nowhere”
Extracorporeal membrane oxygenation, or ECMO, can be a lifesaving technology for patients whose organs have failed. It works, essentially, by performing the functions that a healthy person’s lungs and heart would normally do.
An ECMO machine pumps blood out of the body, removes carbon dioxide and adds oxygen, then returns the blood back to the patient’s body.
Many recipients of ECMO treatment can walk, talk, even ride a stationary bike, but they can’t leave the hospital with the machine, nor can they survive without it. In a recent article in The New Yorker, emergency physician and writer Clayton Dalton described these patients as “caught on a bridge to nowhere.”
Marketplace’s Lily Jamali spoke to Dalton about the complicated ethics of this technology. The following is an edited transcript of their conversation.
Clayton Dalton: ECMO, in and of itself, doesn’t really fix any problems. You have to be headed somewhere, and that could just be recovery, right? You can put someone on the machine and let their lungs recover. That’s sort of the model that was used during the COVID-19 pandemic. Or if they’re not going to get better, then you hope that you can get them a transplant, but you don’t know that in advance. It’s hard to know if someone will be eligible for a transplant far in advance, then things can change that could disqualify them, and it’s superhard to know if someone’s going to recover on their own or not. And so, it’s a bridge. It’s a bridge to get you to recovery or to a transplant, and we just don’t know if either of those things will happen when we pull the ECMO lever. And what can sometimes happen is we put patients on the machine, and then neither of those two things happen. And it’s really ethically thorny and difficult because you could have a patient who is awake and essentially feels good, but this machine can’t be used outside of the [intensive care unit] because it’s still very complicated, and so they’re sort of stuck in this place. And this seems to be happening more and more because the technology is more available and we’re using it more. And [we] have to eventually have a conversation directly with the patient and say, it looks like we may have to start talking about a day when we turn this machine off, and then they would die.
Lily Jamali: And let’s talk about a specific example from your piece. You write about a teenager in a New England hospital that you describe as being caught on this so-called bridge to nowhere. What happened in that case?
Dalton: It was a really tough case. He was a teenager and was put on the machine to try and get him to a transplant, and then the doctors found a new problem that made him ineligible for transplant. And because of the nature of his illness, he wasn’t going to get better. And he was in the situation where he was awake, feeling good, seeing his friends and family who would come to visit the hospital and was deriving some benefit from being on the machine, some enjoyment, and obviously didn’t want to die. It was an incredibly complicated ethical situation because the doctors felt like they had to be steward of this resource because other people might need the ECMO machine and could benefit as well. And so there was a lot of disagreement in terms of how to approach that problem. Do we choose a day to turn the machine off? Do we let the patient live indefinitely in the ICU until something bad happens? These machines do come with complications, and so usually something will happen, often something sort of catastrophic. And in this case, there was sort of a compromise that was reached where instead of turning the machine off or maintaining it indefinitely, they stopped maintaining it in the same way. And so, the machine sort of eventually wore out, and the patient passed away. It’s still a really difficult situation, and I don’t think anyone felt like there was a good answer.
Jamali: Yeah, it sort of touches on ethical questions at the heart of this ECMO technology. Can you talk about what’s really at the heart of that debate?
Dalton: Yeah, I think what’s interesting to me about this technology, though the technology itself is interesting, is that it seems like the real challenge here is figuring out how to use this technology wisely. This is the challenge of nuclear weapons or the internet or this will be the challenge of artificial intelligence. It’s almost like the challenge of figuring out how to be good stewards of these technologies is more challenging and complicated than inventing the technology itself. And I think that’s true with ECMO too. Not to say it wasn’t an incredible innovation to develop this technology — it was. But now understanding how to use it carefully and judiciously is going to be challenging. We are afraid of death as a culture, and if we have a machine that can essentially forestall death, we’re going to use it even if it’s not the best choice.
Jamali: And how much does this debate over ethics concern you as a doctor yourself?
Dalton: It is concerning to me, and I think this is not a new problem in medicine. It’s an old problem. And as we develop more and more sophisticated technology, the sort of default is to use it even in situations where a patient is simply naturally dying. It’s hard for us collectively to accept that. And so, we use everything. We put them in the ICU, we use dialysis, we use breathing machines. We use ventilators. And if you’re irretrievably dying, that’s not a very good way to die. And I am concerned that adding another even more sophisticated medical technology in some circumstances can feed that. Certainly in other circumstances, people’s lives will just be saved. It’s by no means black and white, but I am worried that there will be more situations in which we’re using it in not as thoughtful of a way as we might.
Jamali: Let’s talk about scarcity a little bit. How scarce are these machines?
Dalton: I think it depends a lot on where you are. They tend to be concentrated in the biggest hospital centers, but they’re becoming more common. And so historically, they’ve been in the big urban centers. But that is changing. The machines are becoming less expensive. They’re becoming safer, simpler, and they’re becoming more widely available, and so we’re starting to see smaller hospitals begin to acquire them. I work in New Mexico, and there is one hospital in the entire state that has ECMO capability, and it’s the [University of New Mexico Hospital] in Albuquerque, and that’s it. If you’re in California, I’m sure there are many, many more hospitals that probably have this technology available. If you are in an even more rural state, perhaps there would be no ECMO circuits available. So, I think it’s pretty unevenly distributed at this point.
Jamali: Yeah. In your piece, you lay out some interesting potential future uses of ECMO in organ transplantation. Can you describe what the future of this technology might look like?
Dalton: Yeah. So, Robert Bartlett, who was actually one of the early pioneers of this technology in the 1960s, is still running his lab at the University of Michigan and is still working on this technology, which is incredible. And he is very much looking to the future for how we can adapt this technology to do, to do other things. And he thinks that we can use it to preserve individual organs outside of the body and perfuse them and keep them alive to create a sort of organ bank so that transplant surgery may no longer be an emergency surgery. You can just find an organ that fits you in a bank and then schedule the surgery. He thinks that we could use this technology to create sort of organ factories, if you can keep organs alive in a lab and then have them make things, make proteins, make medicines. So, he’s very excited about the other ways that we can adapt this technology to do other things, and those things may happen, and perhaps that will be transformative. I think that the future will be a mixture of these two things. In some ways it will be transformative and will revolutionize medical care, and in other ways, it will complicate what we do. As physicians, part of our job is to steward people through the various vicissitudes of life and help them try and make the best decision, which isn’t always doing more or using more technology. And that’s always hard.
At the height of the COVID-19 pandemic, ECMO was a beacon of hope for some critically ill COVID patients, but as Dr. Dalton said in our conversation, scarcity is a problem with this technology, even more so when hundreds of thousands of people were getting sick each day.
In a story from 2021, The New York Times reported that hospitals across the country had to ration ECMO treatment. Some patients were placed on waitlists. while others with underlying conditions were rejected altogether.
One doctor in California told the paper that for every COVID patient who survived with ECMO, there were probably “three, four, or five people that die on the waiting list.”
Elsewhere, according to KFF Health News, nurses at some hospitals reported taking 10 to 15 calls a day from hospitals and desperate families looking for available ECMO machines.
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