 Our next speaker is Dan Bronner, who is a geriatrician and associate professor of medicine at the University of Chicago and an assistant director of the McLean Center. His research has focused mostly on aging issues, so dementia, maternalism, the doctor-patient relationship, nursing home care, and he uses a variety of innovative methods such as the principles of linguistics in communicating with people with dementia. Dan will talk about how to avoid the do not ECMO order, DNE. Thank you, Marshall, and thank you to Mark Siegler and everyone involved here at the Clinical Mental Ethics Center. Today I'm going to talk about a topic that's dear to my heart. Actually it came out of a request for papers that will be coming out in an issue of the AMA's Journal of Clinical Ethics, which one of our former fellows, Elizabeth Sontag, is editing. So to begin with, people have highlighted problems with American medicine. One of the high costs, the lack of access, and of course health disparities. But there's another problem that isn't talked about that much, and that's the onslaught of medical procedures performed on patients without sufficient attention to their expected effectiveness. And this onslaught is most strikingly represented and is paradigmatic in the way we use CPR for all cardiac arrest. Default CPR became the treatment for all patients who died in the hospital in the early 1970s, and I'll help triangulate that moment later in the talk. And it created a template for the standard of doing everything. And there's currently a fear now that is new life saving technologies become increasingly accessible, they too will become added to the everything doctors do and patients come to expect. So ECMO is one such therapy that people, that there is concern about that this will happen too. And this is a graphic representation of different types of ECMO, extracorporeal membrane oxygenation. ECMO is a life-supporting treatment which supplants the function of the lungs, the heart, or both. In its earliest incarnation, it was termed the mechanical heart and lung. And it was first successfully applied in the 1950s and actually revolutionized cardiac surgery. So this morphed into ECMO after the development of a compact portable battery-operated roller pump in the 1960s. This freed it from the operating room and led to an expansion of its indications into acute respiratory distress syndrome, ARDS, as a bridge to transplant in cases of overwhelming sepsis, and also in cases of resuscitation. And the use of ECMO in the treatment of cardiac arrest is fairly short history. The first successes as an adjunct in CPR were described in highly selected cases of cardiac arrests and it was reported first in 1976. There wasn't a lot of enthusiasm for that for a while, but in the last 10 years, this is a greatly increased. It's now called extracorporeal cardiopulmonary resuscitation, or ECPR, and it, as I said, is increased greatly in the last decade. According to a recent meta-analysis, it's, quote, considered an alternative resuscitative method for patients who have a presumed reversible etiology of cardiac arrest, acute MI, PE, etc., who show no response despite advanced cardiac life-saving maneuvers in the ED, the ICU, and the cath room. This is from the meta-analysis. So there's been consciousness about the limited indications for ECPR, especially at the current moment these limited indications appear fairly well-established. They were echoed in an editorial commenting on a study of 12 years of data from the Extracorporeal Life Support Organization, or ELSO, defining the indications for ECPR as, quote, the implementation of veno arterial VA ECMO in a patient who experienced a sudden and unexpected pulse-less condition attributed to sensation of cardiac mechanical activity. And I italicized those sudden and unexpected because I wanted to emphasize that here. It's not all cardiac arrest. But at the same time that the current standards for ECPR stipulate limited indications and specific locations for its use, experts cannot help wondering about further expanding its application. In an editorial accompanying the recently cited meta-analysis, it was titled, Are We Ready for Prime Time? And the subtext of that question, really, I think is fairly obvious. And it is, should ECPR become part of the CPR protocol? But the editorial, to its credit, cited that despite the two times greater survival to hospital discharge and those receiving ECPR as opposed to regular CPR, the editorial concluded that the data was actually incomplete and that ECPR should only be performed in a selected circumstances in those institutions that have 24-hour-a-day extracorporeal support systems in place. They also conclude in the paper, as most papers do when they talk about ECMO, that quote, ethical considerations as to who should receive ECPR and who should not get it need to be properly addressed. And this raises the question of what should the role of ethics be in this question? So far, there's not been a lot of work on this from the ethics community, but in this review written by Riggs Becker and Sugarman from Penn and Hopkins, they predictably they call for more evidence about benefits and risks, they call for surveys, evaluating the preferences of potential patients, which is pretty much everybody, and also that there should be some consideration of the economics. However, another role for ethics, which I'd like to provide, is to provide an historical perspective, perhaps a cautionary tale about the early parallel history of CPR and the forces that influenced its evolving indications to become the default. So this is a rather brief history of auto work that I've done in the area. Okay, the treatment of cardiac arrest when it evolved, open cardiac massage was largely confirmed to the operating room until the 1950s, sort of mirroring ECMO as well, which was initially just located in the operating room. The indications greatly expanded when the closed method was developed in the late 1950s. This is a paper I've shown many times, and the thing I like to point out here is that this is the first paper reporting on a series of patients undergoing resuscitation, the first series of patients undergoing resuscitation with a new technique at Hopkins in the late 1950s and early 60s, and the important part here is that they report a 70% success rate, and people have wondered about that. The reason they had a 70% success rate is because the indications for the procedure were extremely limited. That is really what defined their high success, what created their high success rate. And in fact, James Jude, who was the only physician on that paper, met with the other sort of progenitors, creators of CPR at a roundtable conference that was held in 1962 in Chicago by the American College of Chest Physicians. And it was moderated by Peter Saffar, who was an important person in the sort of helped bring back mouth to mouth resuscitation as an important part of CPR. And so Saffar starts the conference, this is actually the first paragraph of the conference. He says, the topic we will discuss today in summarizing form is cardiopulmonary collapse, which we consider to be synonymous with cardiac arrest. I would like to define cardiac arrest as the clinical picture of sensation of circulation in a patient who is not expected to die at the time. This naturally rules out the serious ill patient who is dying slowly with an incurable disease, the patient with a CBA, and patients with similar disorders. Of course, obviously we've become more adept at treating a lot of these things, but he's talking about terminal conditions at the time. And he asked Jude if he agrees with this definition, this limited definition of cardiac arrest. And Jude replies it's a very good one. And we see sort of a very similar, this is similar to what they're talking about, with ECMO and having limited definition of cardiac arrest. Jude then, just to get an idea that this was the sort of practice throughout most of the 60s, Jude comes out, writes the first manual on CPR in 1965, it's published, and he actually starts out number one in his introduction. The patient must be salvable. CPR is indicated for patients who at the time of cardiopulmonary arrest is not in the terminal stage of incurable disease. And this line here is, I think, really salient. Resuscitative measures on a terminal patient's will at best return them to the dying state. So this is 65, they knew this. And it really did inform the practice in many hospitals at the time. This is another paper written in the 60s and the later 60s just to give you an idea that the standard of the default had not yet been established for CPR. And this is written by a lawyer, George Fletcher, in the AMA when they had a series on medicine and religion. And he says the moral of our circular journey is that doctors are in a position to fashion their own law to deal with cases of prolongation of life. By establishing customary standards, they may determine the expectations of their patients and thus regulate the understanding and the regulation between doctors and patient. And by regulating that relationship, they may control their legal obligations to render aid to doomed patients, suggesting that the standard of the default had not yet been created. And he then makes a, he gives a challenge to the medical profession. And he says the medical profession confronts the challenge of developing humane and sensitive customary standards for guiding decisions to prolong the lives of terminal patients. This is not a challenge that the profession may shirk. Unfortunately, the profession sort of did shirk it and the default was developed in the early 70s. And part of the proof of the development of the default in the early 70s is the then secondary response to the development of default in the DNR order. Without a default application of CPR, the DNR order is not required. And the first evidence for this, the first mention of DNR order in the medical literature is found in the Canadian Medical Association Journal written by actually a chief resident in psychiatry at Stanford. And he talks about DNR patients in 1972. And that's the first, the first mention of that in the medical literature. There's also mentioned in the linguistics literature in an article about the language of nursing that comes out in 1973. So sometime shortly before that is the creation of the default. And then in 1974, you have the order not to resuscitate, which was written by the American Heart Association and published in Jaman, a big supplement of reference to here. So some forces for the expanding indications for CPR, which throughout the 60s was expanding. I mean, probably it's the last one here, the technique being less aggressive. And there not being an obvious downside, which of course, we know there are now, to resuscitating patients was a factor that greatly increased its practice. The uncertainty involved in whether or not we know whether the procedure will be effective is also often cited as a reason for applying it to everyone. But I would, I would posit that uncertainty is something that we deal with all the time in medicine, that lots of the things we do are uncertain. And still, we don't, you know, apply every procedure to every patient because we're not sure whether this particular procedure will help or not. We have some knowledge about what's going on and we act accordingly. Also, the time factor has been cited as a problem, as a force for creating the default. But again, this presents more of a methodologic problem than it does a philosophical one as to who should get the procedure. The time factor has been known for resuscitation for hundreds of years. And it was only in 1970 that it became the default. Another force that's often forgotten in terms of the application of technology is the technological imperative. And this was been appreciated at least since the 1980s when Howard's viral encapsulated the force, which he saw driving the increasing application of technology. And when he said it was a conference entitled the technological imperative held in 1980 actually and published all year later. And he says, we are all encouraged to do more in the way of technological activities today than 10 or 30 years ago simply because the third party payers pay for technology and not for thinking. When you talk with the officials, they point out that it's easy to assess the cost of the procedure, but difficult to assess the cost of the thought. And so in many ways, this is what sort of drives the standard of care. And so what happens in 1970, which really is, I see as the ultimate force for creating the default, has to do with the current procedural terminology, which is a list of billable procedures originally put out in 1966 as a rather small volume, but then was 70 percent larger in this second edition that was published in 1970. And on this, listed as a billable procedure for the first time is cardiopulmonary resuscitation for cardiac arrest, 96,000. And it was shortly after that that we see the development of the default for CPR. So let's look at the CPT codes for ECMO. The first instance of CPT codes for ECMO appear in the fourth edition published of CPT, published in 77, and it's a single code. After several revisions, the current code for ECMO were established in 2015 with 16 different codes referring to different aspects of the ECOM, more of the procedural aspects. Interesting, the codes are not linked to Pacific indications as with the case for CPR for cardiac arrest. And that perhaps is part of the difference. And this actually suggests a possible solution. So one way to avoid ECPR becoming a default for all cardiac arrest is not creating a CP code that links it to cardiac arrest. And in conclusion, the gauntlet has already been thrown down for hospitals to provide around the clock ECMO teams before they will be sanctioned to provide ECPR, paralleling the creation of co-teams for CPR in the 60s. And it's really only a matter of time before the data will be collected that conclusively and in controversial shows that ECPR is superior to conventional CPR but only in select patients. And now is the time to create sensitive and humane standards for the application of the ECPR that honors the evidence that is amassing about its effectiveness. So learning a lesson from CPR, cardiac arrest that includes all cases of sensation of blood flow should never be a blanket indication for ECPR. Patients should not have to become do not ECMO or DNE in order to avoid this therapy. Instead, physicians need to make judgments about who will benefit from the procedure and decide with patients and families if this invasive treatment is something they would want. By raising the stakes of resuscitation, ECPR has forced doctors to better define the limits of resuscitation. Perhaps the lesson of ECPR should be retrospectively applied to CPR as a truth about the value of ECPR must surely also apply to its early incarnation. Thank you. I have a quick comment slash question. Hannah, I'm a former ethics fellow. I love your lecture, I've seen it before, but I think this has a more specific ECMO bent to it, which I appreciate. What I thought was really interesting is that JAMA article from the 60s that you put the snippet of at the bottom says all you need is two hands. And I think that's certainly not even the case anymore with CPR, requires more than two hands. There's also now Lucas device, things like that, that increase the cost of care involved in these procedures. And ECMO just exceeds that in every respect compared to CPR itself. So I think as far as the comments you make about humane and sensitive standards, we also have to consider the health care costs that go into these procedures, which I think should also drive the selectivity that we have in making sure that we're doing this for the right patients. Yeah, yeah, I think cost is an important factor here. But as you can see, I mean, the cost becomes something that that is that is created when you put it on the list and make it a billable procedure that that in some ways creates part of the cost. There is the cost of just the human activity as well. Yeah, I think for me, yeah, I think that's a part of what I meant by cost is the human capital itself that goes into managing ECMO patients, the the bed that's taken by ECMO, the ECMO nurse, the ECMO tech, the residents and or other academicians who are at the big center that the patients now at to manage them. Yeah, it is. I love the talk. Thank you. Back and ask the same question about the ED for a moment. And the actor that you might, if you can comment on the actor of the expectations of the patient, you know, the challenges we face in the ED with CPR are many. And I actually did a recent study of emergency medicine physicians who felt that those expectations drove what they did. So you know the challenges about slow codes and all these other things about expectations of patients and what they see on TV and how residents actually feel they don't have the ability to say I'm not going to start actually because there's no value here. Can you comment on the implications for that perspective of what the patients bringing in or what the society is expecting with ECMO, right? Right, you know, I think at this point ECMO remains sort of not that well appreciated. But I think as it becomes more and more applied, people are going to going to see it as something that may be potentially lifesaving. And I think I think the medical community has a large responsibility at this time to really be very clear about its limitations. I mean part of the problem with a lot of these procedures is the people who do them and research them are often their advocates. And so that they love talking about how effective the therapy is. But I think, you know, remembering what those guys were doing in the 60s, you know, when James Jude was talking about the fact that this is procedure has very limited indications. And ultimately his voice was drowned out. I think by in large part by the economic incentives of creating a procedure that you could do for everybody who died, which I think is very wrapped up in this. But I think we really have a responsibility to sort of inform people about the real limitations here and also the burden of the therapy. And I think the stakes being so high in ECMO, the invasiveness of it,