Palliative Extracorporeal Membrane Oxygenation Decannulation: An Ethical, Evidence-Based Approach

BACKGROUND: Extracorporeal membrane oxygenation, although lifesaving, is invasive. Complications affecting all body systems mandate reevaluation of goals of care. When extracorporeal membrane oxygenation is nonbeneficial, planning for de-escalation/decannulation to allow natural death must occur. LOCAL PROBLEM: In a tertiary care facility with 64 beds using extracorporeal membrane oxygenation, practices varied regarding extracorporeal membrane oxygenation initiation, patient/family communication, futility determination, and symptom management during de-escalation. Symptom management during transition to comfort-directed care was suboptimal, increasing patient, family, and team discomfort. The goals of this quality improvement project were to mitigate practice variability and improve patient experience and communication, allowing for comfortable, natural death. METHODS: Palliative care integration, literature review of best practices, and creation of an interprofessional task force were process improvements during extracorporeal membrane oxygenation de-escalation. New clinical guidelines provided structure, consistency, and evidence-based care processes mitigating practice variability during de-escalation/decannulation. RESULTS: Successful guideline implementation decreased practice variability, lessening patient/family stress and discomfort. After implementation, team member self-reports of secondary trauma and moral distress symptoms during extracorporeal membrane oxygenation de-escalation/decannulation decreased. Team members reported improved end-of-life care delivery with family education and support, patient advocacy, and symptom management. Family members appreciated attention to the patient's and their own well-being during end-of-life care. Structured debriefings helped staff members process feelings toward end-of-life care and identified opportunities for improvement. CONCLUSION: Guideline application decreased practice variability in extracorporeal membrane oxygenation de-escalation/decannulation, incorporating patient and family preferences. Death became more comfortable and dignified. Decreased practice variability and proactive symptom management improved patient/family experience.