 Good afternoon. On behalf of the planning center, I welcome you to today's lecture, you know, a series on ethical issues in end-of-life care. Next Wednesday, in this room, Dr. James Colpatrick from the University of Pennsylvania will give a talk on ethical considerations in palliative care and cardiovascular implantable electronic devices. That's next week. Today is my pleasure to introduce our speaker, Dr. Ken Prager. Ken is a professor of medicine at Columbia University, where he is also the director of clinical ethics at the University Center for Bioethics. Dr. Prager also serves as director of medical ethics at the New York Presbyterian Hospital and is chairman of the Medical Ethics Committee, also at the New York Presbyterian. Ken earned his M.D. degree from Harvard, followed by a residency at Columbia in New York, and he then became chief resident here at Chicago in 1972-73. I had been chief resident a couple of years earlier, but during his chief residency year, we became lifelong friends and colleagues. Ken Prager has received many honors for his teaching, clinical expertise in medical humanism. He was awarded the Columbia Presbyterian Medical Center House Staff Award for Excellence in Clinical Teaching, Columbia University's E-Wake Clinical Education Award, and is also a recipient of the Arnold Gold Foundation's Leonard Tao Humanism and Medicine Award. Dr. Prager's writings on medicine and medical ethics have appeared in major medical journals and textbooks, but I always love his short essays that appear in the New York Times and the Wall Street Journal. I didn't say it, but Ken is a pulmonologist as his specialty area. Today, Dr. Prager will talk to us on, I think the title is up there, ECMO as a bridge to nowhere, ethically challenging point-in cases from the technological edge. Please join me in giving a warm welcome to Ken Prager. Thank you very much, Mark. This is really a little bit of a homecoming for me. I was just saying to Dr. Siegler, the last time I was in this auditorium was about 43 years ago when I was the Chief President here. One of the jobs of Chief Residents in those days was to organize grand rounds, and I always was sort of behind the eight ball and always having a panic. I have absolutely nobody to speak for grand rounds. But really, I haven't been in this room for a long time. It hasn't changed much. So it's really a bit of a homecoming for me. I had a wonderful year here as Chief Resident, and as Mark said, we've remained close friends ever since. So I appreciate very much, and I'm honored to be asked to come and speak to you about a subject that is very challenging and is also dear to my heart. It's interesting also that both Dr. Siegler and I ended up in medical ethics independently by different pathways, and I think part and parcel of it was the fact that in the olden days, and I hope it's still true, internists were trained in humanism and old picture of patient medicine. For me, with the advent of medical ethics in the 1970s, I didn't see the need for this new discipline, because this is what every doctor was supposed to do. But I have learned over the decades that follow that, in fact, we do need a discipline in order to uphold some of the standards that we took for granted in, as I say, the olden days. Well, I'm going to speak today about ECMO and the ethical challenges. The first thing to do is tell you what is ECMO, and the outline, as you see, it is one of the goals of ECMO treatment. I'm going to present a case study, and then I'm going to speak a little bit about the ethics of withholding and withdrawing this form of treatment. And then another aspect of that ECMO, whether or not you do not necessitate orders are appropriate or meaningful, even when people are on this type of technology and present briefly a second case and then summarize. So what is ECMO? Well, first of all, it's an acronym, and it stands for Extra Corporeal Membrane Oxygenator. And this is a schematic diagram, and you can see here that you have a patient who is over here, and the purpose of ECMO is to oxygenate the blood when the lungs are failing, and they can no longer oxygenate, but even if the patient is on a respirator, even if the patient is getting 100% oxygen. In addition, the ECMO machine can assist the heart that's failing, and there are two types of ECMO, which you'll see, but what happens technically is that the venous blood is taken from the femoral vein and goes through a pump. The pump then pumps the unoxygenated or poorly oxygenated blood into this oxygenated device, and across a permeable membrane, oxygen, which is taken from this blender from the air or from the supplemental oxygen, the oxygen molecule is diffused into the blood, the carbon dioxide diffuses out, the carbon dioxide is not rid of. The blood then returns into the venous, or either in the venous system, in which case we call it venobenous, VV ECMO, where the purpose of the machine is simply to replace the failing lungs, but the heart is working okay. And there's another form of ECMO called VA ECMO, where in addition to oxygenating the blood, the pump propels the blood actually into the arterial system and assists the failing ventricle. And that you'll see in the next slide, so there are these two types, venobenous, which again is for people who have a relatively pure pulmonary failure, and veno arterial for people who have both respiratory and circulatory failure. This is a picture of what ECMO, I can't see too well here, but this is 1972 when the first ECMO machine was invented in California. You can see it's a huge device and there are multiple tubes. It's extraordinarily complex and this was invented in order to try and save the lives of people who had ARDS, acute respiratory distress syndrome, with failing lungs. It worked well with all four adults. It worked much better for infants. And for the coming decades ECMO was and continued to be used really to assist infants who had pulmonary failure, but it was really dropped for adults until about 15 years ago. It made a renaissance and crossed up technological advances. And so this is what replacing a lot of that paraphernalia that you saw in the previous slide. This is 10 by 12 by 17 inches. It's one of the components of the ECMO devices. And here you see again a schematic diagram where you have a much smaller and much more effective device. It's a pump to control panel which controls how much oxygen, how much carbon dioxide you want to remove, and oxygenator itself. And the blood is coming out from the venous system, from the emerald vein. And it's being returned, it can be returned to the right atrium, in which case then it goes through of course the tricuspid valve, argonium, the lungs. Or it can also be returned, this would be VV ECMO. It can be also returned into the arterial system in the case of VHA ECMO. What do we use ECMO for? Well, when you have somebody with either a failing pulmonary situation, we can, let's say you have somebody who comes in with ARDS, and we had a good number of cases during the H1N1 epidemic. We had people, young people, who were dying of ARDS secondary tumultulenza that we put on ECMO at Columbia, clearly whose lives were saved as a result. Those who survived most of them did. As a result of this, that was what was called the bridge to recovery. These people were put on ECMO. ECMO is not a destination device. You can't go home with ECMO, you can't even leave the ICU with ECMO. So either you live or die on ECMO, that's the bridge to recovery. If you put some other patients on ECMO, it can be a bridge to decision when the prognosis is uncertain. Now in the Far East, they actually have mobile ECMO teams that come to people who have cardiac arrest in the field and they will cannulate these people. It's called E-CPR, extra corporeal CPR, where they will actually hook you up to an ECMO machine. And the outcome, of course, is very uncertain, depending on multiple medical factors. We don't do that here in the States. It is something that will probably eventually occur and will lead to, I'm sure, many more evidence on this as you'll see. But then you have bridge to transplant. This is something that we use on a regular basis because Columbia is a big pulmonary lung transplant center. So these are people who have been evaluated. The only way that they can be helped is with a lung transplant. And while they are on the waiting list, they deteriorate. They remain a candidate that all their psychosocial issues have been worked out, but in order to stay alive until a lung becomes available, they are put on ECMO. Now, ECMO can't last forever. It can go on for two, three, four, five weeks. Then you're pushing it. People then begin to get major complications and die. But it gives these people a month window to get a set of lungs, or one lung, so that their life can be saved. And that is bridge to transplant. Bit bad, ventricular assist devices, which I'm sure some of you are more familiar with in ECMO, is a similar type of situation where you have a mechanical device that can assume the roles of the heart until the patient receives a heart transplant. And then there is the possibility of putting somebody on ECMO as a bridge to a destination device, for example, of that. What happens in that circumstance? You may have somebody who goes in for a coronary artery bypass operation with cabbage, and they crash on the table, and they have a combination of both acute pulmonary and cardiac decompensation. In the olden days, they would die. They would come out of the OR, they'd be dead. Today, the surgeons put them on ECMO in the operating room and let the dust settle and see, will these people then be able to be kept alive on ECMO? Will they need a pad, a ventricular assist device, or will they have enough cardiac and pulmonary recovery so that they won't need any sort of assistive device? And currently, we have no destination pulmonary advice. There is no VAD for levels. There's only a ventricular assist device for heart, and ECMO, as I said before, is not the destination device. Does ECMO, in fact, include survival? Well, there's really a quantity of data on this. However, there was one randomized trial called the Caesar Trial in England which supported the use of ECMO for severe hypoxemic respiratory failure. There are many people with ARDS. There are other smaller trials which showed mixed results. And there's now a multi-cent randomized trial which should better define ECMO's role in respiratory failure. I will say it depends a whole lot on who's doing your ECMO. At Columbia, I'm proud to say we are tops. We are one of the best in the world, and our results are excellent. We have seen catastrophic results of people who use ECMO to other hospitals without the training, without the expertise, and it does not go well. So if you're going to do a trial, you have to do it with the people who know their stuff. Otherwise, your results will be very skewed. But complications of ECMO are considerable. You get bleeding in 30% to 40% of patients, which may be life-threatening. What is particularly distressing is that there's a significant incidence of brain problems, subarachnoid hemorrhage, ischemic watershed infarcts, hypoxic ischemic encephalopathy, unexplained coma, and brain death. You can also get, if in VA ECMO, if you take over the work of the heart too much and there is little circulation going through the ventricle, you can actually get a clot in the ventricle because you're not giving enough preload of the ventricle. You have to know what you're doing. And of course, infection is always a possibility. One of the issues that are unique to ECMO, after all, we have a lot of other assist devices. We have VADs, we have dialysis, we have ventilators. Well, there are a couple of issues that are unique. Number one, patients in ECMO have to stay in the ICU. That's not true of VADs. It's not true of ventilators. It's not true of dialysis. Number two, it is a very high resource utilization intervention. You must have an experienced, multi-disciplinary team that's tying up a lot of people. You need the ICU bed and it's quite expensive. And then you get, and this is not necessarily unique to ECMO, but you see it more with ECMO than we do in some of the other interventions. Although I think you could probably substitute VADs here as well. Circumstances may arise when a patient on ECMO may be unable to be bridged to any of the aforementioned destinations. They're not going to be a transplant candidate. They're not going to recover. And they don't have a destination device for lungs. So you have the patient here who can be awake and alert on life-sustaining device, but they are going nowhere. They are going to die in the hospital. The patient may be awake and alert and capable of surviving for weeks before complications arise that lead to death, the so-called bridge to nowhere scenario. And how does this arise? What are the clinical circumstances where this can happen? Well, you can have, for example, somebody who's dying of heart failure and they're put on an assist device in an emergency situation. Again, somebody comes into the hospital in a major massive ally in cardiogenic shock. They're put on a VAD or ECMO. And we don't have time to take the psychosocial history and look at their bed. You either treat them with this intervention or they're dead. Obviously, we have to give these people the benefit of the doubt. They're put on the assist devices. And we can't do appropriate assessment whether adequate psychosocial support exists for patients to qualify for cardiac destination devices such as a VAD or a heart transplant should they need them and whether or not they will meet appropriate medical criteria. So you can end up with a VAD bridge to nowhere, just as you can with an ECMO bridge to nowhere. A second scenario, which I'm going to show you a case of, is a patient who's on the transplant list for lungs. They may decompensate suddenly, require ECMO to stay alive in order to reach the transplant. However, once they're on ECMO, new medical or sometimes psychosocial issues are revealed that may disqualify them for transplants so they're going to nowhere. They're going to die in a hospital. Even if it is clear at the outset and sometimes it is clear that a patient requiring ECMO will not be a candidate for a harder lung transplant or for a destination device, how do you know that this patient might not be a bridge to recovery? So you give the patient the benefit of the doubt. Turns out the patient's not going to recover. Their heart will never recover and their lungs will never recover if you have a bridge to nowhere. It is difficult emotionally and ethically to deny a patient a chance for a bridge to recovery but they're not candidates for transplanted destination device and there isn't a reasonable chance they might be covered to get off ECMO. This is how much of a chance, how much do we give the patient sort of the benefit of the doubt and I can tell you that being human beings, surgeons and cardiologists and pulmonologists will give people the benefit of the doubt even to a greater degree perhaps than sometimes warranted. So the ethical dilemma is clear. Once patients are on ECMO they're not candidates for either transplanted destination device and it is clear that they have no reasonable chance of recovery to allow ex-clamp a lot then. What to do then in a, there was an article written in 2008 by Ramstead, the American Society of Artificial Internal Organs who actually spoke about this situation at Bridge to Nowhere and the author of this article felt that we did not have an ethical or legal obligation to provide futile intervention and interventions. Before a patient should get implanted bad he felt that everybody should have advanced directives. We should try to have these discussions to help avoid these dilemmas and here's the quote though that I want to show you. In the article he states, futile interventions that are in place should be discontinued and demands for continuation of futile therapy should not be bothersome. Notice he said should be discontinued. So it would seem that the author of this article would have a rather tough stance shall we say and if it is futile in the sense that the patient has no chance of surviving discharge he would argue that we can discontinue this. We should not honor demands for continuation of futile therapy. They went on and spoke about to avoid these destination to nowhere. Let's try to prophylactic this. Let's try to make it not happen. Let's have strict selection criteria. It's emotionally easier to withhold putting the patient on the device rather than withdraw it. And a quote from the article the ethical challenge for bad teams is to use destination therapy for patients evidencing the capacity to benefit from it. Resisting the temptation to help patients in situations well when destination therapy is likely few. Well it's easy to say that but as I tell you when people are coming in you don't have the time you don't have the opportunity to really go through this evaluation. Yes ideally we would be able to sit down and think about these issues but too often it's emerging. There was a review in the Mayo Clinic proceedings in the Mayo Clinic reviewed removing withdrawing ventricular assist devices in their hospital. And they reviewed 68 patients from 2003 to 2009 who underwent bad placement and 42, 68% two thirds of the patients survived and one third of the patients who had a bad place died. In about half of those who died ventricular assist device was removed at the request of surrogates well about 14 cases. Presumably the patients were too sick to make that decision. In two of the 14 cases however the patient actually made a request. The particular details I don't know but presumably the patient realized the futility of it that made them suffering emotionally physically and asked the device to be discontinued but you can see that in the vast majority of cases it was the surrogates who made that decision. In no case, no case was the assist device removed against the wishes of the patient or the family. Who weren't these patients? What were the bad put in? Well of those who died seven of them the bad was put in as a destination therapy but what happened was they developed obviously complications and could not be sent home. There was a bridge to transplant and six and a bridge to recovery one. What are the options then when you have somebody with a bad or an X model and you have the bridge to nowhere what are your options at that point? Well, you can terminally explain the device with the patient which is infrequent or the family when the patient lacks capacity with their consent. That's one possibility and that's you saw in the Mayo Clinic procedure that the most common thing was when the family made a request. You can in theory explain the device against the patient's wishes. Now that's illegal in New York State. New York State is very clear that and I'll show you some of the criteria to remove life support in New York State. You have to fulfill one of three criteria and it has to be we express consent for the patient if the patient lacks capacity then I'm the surrogate or the health care agent. The third option would be terminally explain the device in a patient who has no capacity advanced directives or surrogates. What if you have somebody who comes in with absolutely from a nursing home. No relatives no advanced directives they crash, they get the device put in, it's a bridge to nowhere and the patient cannot survive can you remove the device in that patient without any advanced directives and without any surrogates. The answer is that in New York State you actually would be able to because in law states that in a circumstance of imminent death is written in the law. If the patient will die imminently regardless of the aggressiveness of treatment then the treatment can be withdrawn. Now how do you define imminent death? We define it as if the patient has no chance to survive to discharge then the patient will die in the hospital. We use that as a definition of imminent death. So theoretically we could remove the life in that circumstance if it was uniformly felt the patient had no chance of surviving the discharge. That's not against the wishes of the patient. It's a case where the patient's wishes are unknown and can't be known. And the final option would be and this sometimes occurs and this is very touching. What happens? The doctors say you know, we're going to if we explain the device, there's a chance a reasonable chance that the patient will make it. But there's also a chance that the patient won't make it. And if you leave the patient and since ECMO is not or if that is, the particular bad being used is not the destination device then the patient is a bridge to nowhere. Do you give some patients a shot to recovery when you're not able to accurately predict. So we've had circumstances like that where we've maximized medical therapy and we have explained the device with the hopes that the patient will survive. Pre-explant informed consent obviously has to be made. Some patients may be frightened of the prospect that they may die with the explanation. Even though they know that with the device in place they have no chance. So you need to have informed consent in a circumstance like that. And the question there is ethically how great must the chances for a successful ex-plant be for a trial of ex-plant to be undertaken and this I think is where your medical expertise and acting really weighs in very heavily on the ethical issues. Now let me present to you the case of Ms. L. This was a 42-year-old single woman from Africa who was living with her mother in the United States since the age of 16. She had a doctor in finance. She worked as an accountant. She was Indian. Her diagnosis was mixed connective tissue disorder complicated by pulmonary fibrosis and pulmonary hypertension and she was admitted to the medical ICU for acute on chronic hypoxemic respiratory failure. The need for ECMO was discussed with the patient as well as advanced directors and we discussed the severity of her lung disease and progressive nature despite aggressive treatment with steroids, diuretics and antibiotics. The patient was told that her only option to survive was a lung transplant and her illness had progressed to the point at which she needed invasive pulmonary support. So, the patient was told there were three possible outcomes. One, you could improve without a transplant after the ECMO was put in and you stabilized and you would take you off the ECMO. However, if that were the case as what I've written down here if she did improve without a transplant this would be marginal and she would almost certainly require chronic respiratory support Now that would be one possibility. Number two is that she might die without a transplant despite the ECMO that she could die because of complications on ECMO or because a lung would not be available. And number three which of course is what we all hoped for that she would have be a successful bridge to transplant with ECMO and then of course that's not the end of the story not everybody with a lung transplant is successful though our numbers at Columbia are getting better and better she might die or live very shortly even with the lung transplant so this lady was obviously in a very critical situation her only chance to have any sort of regular life once again was to go on the ECMO to get a bridge to transplant to get along to have a successful transplant The patient said that she would not want to be kept alive whether it be ECMO and mechanical ventilation and by the way many of the patients if not most are on the ventilator as well as getting ECMO because you put them on the ventilator so their lungs can contribute somewhat to oxygenation it's not a black and white situation and besides when you take patients off ECMO they usually will require mechanical ventilatory support for sometimes until they're weaned from that as well she underwent ECMO placement intubation and tracheosity during the procedure she went into cardiac arrest she was very tenuous she was resuscitated and she was placed successfully on ECMO and intubated however in the ensuing course of her hospitalization she developed significant complications she got VREF a vancomycin resistant enterococcal urinary tract infection a tension pneumothorax which required a chest tube lung collapsing under pressure requiring a chest tube in order to decompress the oral space and eventually she developed multi-drug resistant flexi-ella in her urine and because of her complications she was delisted from getting lung transplant she would not get a lung transplant three major reasons the transplant came stated number one she was very decondition and patients who get lung transplants in general are going through pulmonary rehab prior to that they're on treadmills with their oxygen we see clearly that severely deconditioned patients do very poorly she was non-ambulatory and she had this incurable infection multi-drug resistant flexi-ella which would certainly destroy the chances of her having a successful lung transplant transplant much as we suppressed these patients so she was not going to get a lung and so she was really it was a bridge to know where she could not be explanted and she was going to stay on the ECMO until she died in the hospital so 24 days after the ECMO placement an ICU physician met with the patient along with nurses on the palliative care team and we have an excellent palliative care team we see these patients almost routinely and the bad patients as well the patient at that time was requiring continuing doses of narcotics for pain and also complaints of difficulty sleeping speaking on the ventilator and generalized fatigue but she was mentally alert she began to tear up instead of the note while talking to doctors and expressed her desire to live longer on ECMO if possible but she realized it was a limit to how long she would survive put yourself in a patient like that relatively young person it's like sentencing somebody to death basically you're on death row you're going to go to the electric chair or the gas chamber within a lump or two or something like that it's a horrible existential distress whatever you want to call it and this again is a patient who is awake and alert the chart stated quote at one point she seemed to understand the prognosis that she would not be a candidate for lung transplant and that ultimately ECMO and mechanical ventilation would be discontinued she wanted to discuss the reasons for being delisted delisted with the transplant team together with her family she felt the decision was made abruptly and she did not understand why eradication of her infection was not possible understand that this is another unique sort of situation when we usually when we have patients who are dying in the ICU they're not going to die for sure because we are withholding a particular form of treatment we can't get their heart better their kidneys, their liver whatever but this lady in her own mind and in her family's mind that she would die basically because the doctors reduced the lung transplant and even though intellectually they might understand that not everybody can get it when it's you in your life and you see death in front of you and it's the immediate cause or the immediate reason in your mind is because you're being denied lung transplant that's a very big hit so to speak and clearly and this happens all the time where families will begin to get angry and upset like and why can't you, this is an infection and all these antibiotics you need to say that she's been set to death because she can't cure an infection et cetera et cetera she said she felt strong and she of course had a desire to live the family members were present for this discussion and wanted all treatments to continue while feeling perplexed that she was delisted for transplant this is totally typical of these scenarios that we see all the time one of the most unpleasant circumstances that I found myself in as an ethics consultant was about two months ago or so where we had a young woman with cystic fibrosis who was not on ECMO and who was not on event later but who was delisted she had had a lung transplant was non-compliant and was not going to get a second lung transplant because of her previous behavior or lack of compliance and she was incredibly angry her family was incredibly angry basically saying so you're punishing our daughter with death because she was non-compliant or whatever and even though she says she will be fine and do everything the next time these are circumstances that you don't want to find these on there and yet if based on experience when you know things will not work out and you will waste an organ that too is an ethically compromised action so these are the sorts of situations that our technology is putting us in today which are very unending and will likely tell you for the doctors, for the ethics, for the nurses for the social workers and so forth a palliative care note said given the change in her transplant status the patient expressed her distress and desire for more information and to have her questions answered with her family present she wishes to live as long as possible but understands that life support therapies will need to be discontinued if she is not a transplant candidate she takes comfort in knowing that she has some control over when she will die but at the moment does not feel ready to make that decision patients usually are never ready sometimes they are but usually not patient wants more information from the transplant team before agreeing to discontinue life support the note continues currently the decision to remove life support and mechanical ventilation needs to be taken with great care the patient is alert interactive and not suffering greatly that's the other thing these patients don't have bed sores they haven't been in the hospital for 3 months they are not aged and have multi organ failure and there usually pain is not that much of an issue the major pain she asked was from the chest that pain can be taken care of she does not feel that the current therapy is not being said there is and should be this note said a limit on continuing both ECBO and NB and a patient who is starting not to be a transplant candidate and they recommended a family meeting with the patient to review the reasons for her not being a transplant candidate and to come up with a reasonable plan as to when to discontinue ECBO clearly she is not ready to have this thought on April the 9th the patient then agreed to no escalation of treatment 3 days later she had more pain the patient interacted but remains withdrawn with eyes closed somewhat lethargic says she will accept increased sedation if it leaves her pain at that point pain was increasing in her chest tube site on the 16th she was resting comfortably quote discussed with patient sister the family's current thought process regarding discontinuing life sustaining therapy feel that as long as the patient is conscious they are reluctant to agree to withdrawing ECBO or NB this is another general statement when you have a patient that you can interact with even minimally so it's extraordinarily difficult for families not just in the ECBO situations but in almost all situations to withdraw life support it's much easier when you have a comatose severely brain damaged patient who is showing no signs of awareness and interaction and this family said look as long as we can still talk to our daughter as long as she is somewhat interactive we will not remove the life support of the ECBO another palliative care note on the 16th we discussed the ethical issue it's interesting that they brought this up we discussed the ethical issue of the allocation of a scarce resource and the theoretical possibility that if there were no more ECBO devices available and there was a need for ECBO to save another patient's life and this therapy may be withdrawn pending ethics consultation as Ms. L. has no possibility for recovery from her acute on chronic respiratory failure it's interesting that they brought this up I actually was not involved with this case we never ended up needing a deathly consultation but is it appropriate really to bring that up if you're not going to really discontinue the ECBO machine anyway against the family's wishes does this help things at all by showing the fact that you know what, your daughter by not coming off ECBO somebody else may die to these more we may feel it it's certainly an appropriate ethical consideration but is this something that the families need to hear do we need to tell families ever your loved one is going to die here they're taking up a bed in the ICU and we have 10 patients in the ER now one of whom needs this bed so I personally have not seen that used I don't think it would work I think it would be very confrontational even though we feel it deeply the family and the patient again the note continues not willing to discontinue life sustaining treatments so long as patients conscious and is not suffering or experiencing the therapy as excessively burdensome on the 20th the patient has had decreased interaction with the family was becoming more agitated now on standing out of that patient controlled analgesia the mandos, she's been started on a morphing drip as adjunct, a fennel drip with good sedation family and team are prepared for discussion of decannulation as the patient is no longer awake or very responsive, lacks capacity prior to being placed on ECMO she clearly stated she wouldn't want to be kept alive life supportive she would have no hope of transplantation to recovery so what happens here is what often happens the patient gets sicker they become more abundant, they may get agitated pain and discomfort, they have to be sedated which frankly is a blessing because it gives the family the opportunity and the peace of mind to say okay, their time is up and just a diversion, a quick diversion in the case of this lady is removal of life support legal in this case? is it legal in there forgetting about the ethics? well we have the family healthcare decisions act which was enacted only about five years ago which states that we can remove life sustaining treatment if one of three criteria are met well certainly if the patient with capacity request seems appropriate okay, not a problem but when the patient lacks capacity the healthcare agent for the surrogate may request if the patient is permanently unconscious or the patient with terminal illness and treatment the patient has a terminal illness they are likely to die within six months and the treatment is excessively burdensome or the patient may not be unconscious, may not have a terminal illness but the patient has an irreversible or incurable illness and treatment would involve such pain suffering around the burden that it would reasonably be deemed inhumane or excessively burdensome under the circumstances clearly in this case the patient has a terminal illness, she is going to die imminently, shall we say, she is going to die in the hospital and if the family feels that the treatment is excessively burdensome then it is certainly a legal term of life support so on the 23rd at this point the patient's medical condition is irreversible, further treatment would be extraordinarily burdensome or cause undue pain and suffering the patient's mother, who is the healthcare agent, requests removal of life support including ECMO and mechanical ventilation which she believed was a key tool for the patient's wishes that was done when the patient died on April the 24th so she had been on the ECMO, we said about it was just a little over a month perhaps about 5 weeks and she was fired the medical decisions one of the decisions that we actually face how can we allow people to die on ECMO without actually turning on the machine we have other options one is we can say no further escalation, for example if the patient becomes hypotensive on ECMO they can become increasingly hypotensive and require pressers we can elect and discuss with the family capping the pressers, we're not adding the pressers we can not replace a failing ECMO component in the machine itself I mentioned the withholding the vasopressers we can make or do not attend for cessation quarter and I'll talk about that at the end of my lecture whether that has any meaning in this situation I turned off the ECMO device which as well was not in this particular case now what was unique then about this patient's end of life scenario she was young, she was alert and she was oriented for most of the time when she was in the hospital she died because a treatment modality was withheld against her wishes, her hopes her expectations although at the very end was it really against her wishes she was unable to express it and that's why I put those three things initially against her wishes her hopes and expectations the current means of life support was time limited as opposed to our other means of life support which generally are not, people can stay on ventilators as you know for years, dialysis etc this is a unique type of life support which has a built in time mechanism of say four to eight weeks the patient had to live out the rest of her very limited life in the ICU it's unfortunate that she could not be moved to a quiet room where there would be more intimacy and privacy for her family the means of the current life support were very resource intensive this is an issue that we again don't discuss with the family but it has to enter into the ethical calculus over here and as I mentioned before ECMO is very resource intensive and expensive and the limited number of ECMO devices in the hospital could theoretically raise potential evidence I'm unaware we have a number of these devices in the hospital during the flu epidemic when we were most pressed but I'm unaware of a situation where we ever could not put somebody on that room because we didn't have enough devices it certainly could happen it certainly could happen now just speaking a little bit about some of the theoretical ethical issues here now about withholding and withdrawing you've heard, I mean again medical ethicist state that there is no ethical difference between withholding withdrawing an intervention or even life support and we routinely withhold in the issue of ECMO and VADS we routinely withhold potential life-longing ECMO and VADS from patients who don't need medical and or psychosocial criteria even against their wishes to receive these devices we will have patients usually with VADS people who will be very upset that the medical patients are not going to put them on a vestridorosis device is there a difference then so since we can ethically withhold these devices because the medical, psychosocial criteria are not there does it stand then that we can withdraw the devices just as ethically if there is in fact no difference between ethically withholding and withdrawing is there a difference then ethically between unilaterally I mean without the consent of family or patient withholding a life-longing device such as VADS or ECMO from a patient unilaterally withdrawing such a device from a patient leading to his or her death if we can ethically and legally unilaterally withhold life-sustaining devices such as VADS and ECMO and we ethically unilaterally withdraw these when appropriate and allow patients to die peacefully and we wrote an article in the chest Dr. Abrams who is one of our national people and it involved myself from ethics it involved pulmonology disappeared in April 2014 where we looked at this and we said why is it that there are cases why is it that there are cases when it is ethically justified to unilaterally withhold ECMO and VADS let's look at that why is that okay these are invasive very resource intensive interventions in the spectrum of treatments it's a step below surgery and it's a step above say a ventilator and dialysis and so we feel ethically that we can set strict criteria for their use patient autonomy cannot dictate the use of every medical and surgical intervention patient autonomy stops at certain points when medical criteria and medical autonomy if you will about the appropriate use of these sophisticated devices trumps the patient's autonomy otherwise we would have to put a VAD in every patient basically regret it a decision to withdraw ECMO from an alert objecting patient in whom it was appropriately initiated but for whom there is now no chance for recovery or transplantation is different from withholding ECMO from a patient for whom the goals of ECMO cannot be realized we wrote this article the argument that because it's ethically acceptable to unilaterally withhold ECMO and VADS it's therefore ethically acceptable to withdraw the use of these interventions is invalid because patient autonomy is stronger in the case of the patient already on a life sustaining device than in the case of the patient wanting the device to be employed patient autonomy would seem to warrant most deference in the immediate life and death situation of removing life support it would be cruel to ignore the request of an alert patient to remain on ECMO and tell her that regardless of her wishes the device will be removed and we don't use that term too often in our medical ethical analysis that it would be cruel to do something but I think that that is a very fitting term in this case if we had gone to this young lady and said you know it's hopeless etc resource intensive etc we will remove this against the wishes it's inconceivable that we would do this the doctor patient continuing along these lines of argument the doctor patient relationship is stronger in the case of a patient in whom an invasive and resource intensive device has been placed stronger than when that patient first comes to see you about assessing their appropriateness of getting the device and as I just said it's inconceivable that an alert patient dying imminently of cancer and reliant on a ventilator for life support would be disconnected from the ventilator against his wishes the only reason to consider removing ECMO from an objecting patient as opposed to the patient with cancer is because of the much greater use of human and material resources. I'm talking about ECMO versus ventilator over here however this alone cannot justify unilateral removal of life support we argue we do not now when it comes to other types of life sustaining interventions in the ICU we don't usually unilaterally withhold other types of invasive and somewhat less resource intensive ICU interventions, ventilators antibiotics, pressers renal replacement therapy, dialysis and so forth. These are among the menu of things that we generally provide patients when they request it even though we may at least be to a Columbia even though we may feel that it's inappropriate these are examples where patient economy is respected in requesting these interventions even if we may think of them as medically inappropriate it follows therefore that we do not generally unilaterally withdraw these less invasive unless resource intensive life sustaining interventions. How can an ECMO bridge to nowhere scenario be avoided? You see the pain and suffering emotionally not just for the patient and family but for the doctors as well. Can we avoid getting into these polls? Well detailed communication with patients and families about the goals of ECMO before we employ it but it's not always possible as I mentioned for emergency situations. The bridge to transplant, it's not emergent. We can have these discussions ahead of time. Bridge to recovery, we can often because these are usually emergency and the bridge to destination ventricular assist device occasionally their emergency and occasionally not. So sometimes we can have these detailed communications but not always. And careful screening of patients for medical and psychosocial contraindications to ECMO obviously has to be carried out. In 2002 we had at Columbia, Dr. Mehmet Oz when you all know not because of his bad work at Columbia but you anybody who reads the paper or uses the TV has heard of Dr. Oz. Well I knew Dr. Oz when and I actually know him quite well. I remember him when actually he was a resident believe it or not he was once a quantified and Dr. Oz made his name before he became a TV celebrity. He was a very very respected and skilled cardiac surgeon. He was one of the prime movers of the early ventricular assist device programs at Columbia. And in now 2002 we're talking about 13 years ago people came to me because even then I was still director of medical ethics and they said you know when their bad devices turned off and sometimes we don't feel as if enough discussion is really, now these were all appropriate circumstances when the patient was borderline dead but there was not a discussion with the family with the patient in the way that people felt that it should be. So I had a discussion with Dr. Oz and Dr. Oz and I came up with a policy so to speak of what to do before turning off and this was one of the earliest attempts to try and deal with this bridge to know where situation with a very resource intensive intervention. So I'll review what I wrote over here. We came up with an article that we published in the Alice of Thoracic Surgery the Ethics Committee of the Columbia Presbyterian Center of the Presbyterian Hospital drafted a statement that patients in positions must review together prior replacement of the car when circumstances don't permit immediately they're at. The statement asserted that the bad restoration hemodynamic stability in a patient with critical myocardial dysfunction may, for various reasons, not reach the goal of enabling the patient to receive a heart transplant or achieve adequate stability to be discharged home on the device. A bad bridge to know where. And this is what the statement that we made up read. Every effort and we wanted the patients to read this and sign this or their surrogates that the patient were too sick. Every effort will be made to help our patients on ventricular assist devices to improve to the point where they meet the criteria to receive a heart transplant or stabilize enough to be discharged from the hospital on that. However, if despite all our efforts, the patient has no reasonable chance of achieving either of these goals, we will discontinue the bad. It wasn't underlined and I'm underlining it for the purposes of my thought. We will discontinue the bad as it will under these circumstances no longer be serving the purpose for which it was originally used. When this occurs, the bad will be discontinued only after the physician's caring for the patient are in agreement that the goals for bad use cannot be met and have consulted with the patient or when the patient is too ill with the family or friends of the patient. So this statement seems like we could unilaterally take the patient off the bad. Did we have to do it? No, we never did. This was, we felt a heads up for families that you know what we could enter into this situation this could happen and we hope that this would make it easier if and when the time came for the removal of bad to be done but only with consent of family or sorry, sorry it was patient. However, the term we will discontinue the bad was in the statement and I think that was probably unfortunate and you'll see that our things have changed somewhat. The current CUNC goals notification document and by the way we used the bad document for ECMO as well. We got calls after that period in the journal by other centers who said you know we have these circumstances over here and we'd like to hear your experience what do you do when you reach these bridge networks and a number of places felt that having a statement like this as a means of communicating options with families ahead of time would be useful. The current document states similarly every attempt will be made to help me this is what the patient would say on the above advice however, despite all efforts I remain critically and reversely ill there's no chance that I can achieve any of the goals set forth by my advice under these circumstances continuing the mechanical circulatory support device would one offer me no medical benefit two, no longer serve the purpose for which it was originally intended three, violate accepted medical standards and four, prolong the dying process I've been advised that the physicians involved in my care are in agreement that none of the above goals for mechanical circulatory support can be met the device will be discontinued again, I underlie before discontinuing the device the physicians will discuss the action with me or if I do not have the capacity to understand with my surrogate decision-maker this is a fudge factor, that second paragraph there we wanted to make a forceful statement that the device will be, it really should say the device should be discontinued I think would probably be more meaningful or a better use of terms and then again at the end it has the caveat that this will not be done without discussion with the family we were struggling with a way with how to deal this bridge to nowhere and with trying to effectively preempt as were dilemmas that would occur by giving the families and the patients a head up now I think going back to this Mayo Clinic article which talked about ethical issues and removing vats so they did something similar now remind, this was seven years after we had the article in the thoracic journal and the Mayo Clinic people wrote since January 2009 all patients being considered for VAT Destination Therapy Placement received consultation with Appalian Medicine Specialist which we do as well who engaged the patients in the process of advanced care planning including completion of the detailed advanced directive referred to as a preparedness plan, it's a nice term the permissibility of withdrawing VAT support is discussed italics line and I think that is a much better way of stating it than what we had done frankly the VAT will be discontinued the permissibility of withdrawing VAT support is discussed as is planning regarding wishes in the event of device failure catastrophic complication development of a secondary comorbid condition or ongoing poor quality of life plans for palliative care should be made for patients who undergo withdrawal of VAT and conflicts related to care management this is at the Mayo Clinic may be prevented by engaging patients in advanced care planning and proactive palliative medicine consultation ethics consultation can be helpful in resolving the limits that arise while caring for these patients now the issue of DNR is it appropriate to write do not resuscitate order somebody who is on ECMO there was an article written by folks at Cornell actually we're one hospital we're supposedly one hospital New York Hospital and Joe Finns who is very well known in the ethics community co-authored this with Melzer and Ivasky when they wrote last spring on the Journal of Clinical Ethics DNR and ECMO a paradox worth exploring they wrote some institutions obtained consent for both the initiation and discontinuation of VA ECMO before therapy begins so that they will not need to obtain consent later to withdraw treatment while no data presently exists on the prevalence of this practice pattern or its effect positive or negative on insurgents and I underline this we find this autocratic and heavy handling particularly when the goal is to avert the subsequent futility dispute this practice even with the best of intentions could be construed as coercive that is in order to receive a life-saving therapy one must also agree to its discontinuation I don't know about other other we certainly never said unless you sign this or on board we're not going to put in the back that was never the intention that's never been done no other form of life support comes with such a stipulation such practices violate ethical norms and state and federal laws such as the Patient Self-Determination Act the surrogates operating under an advanced directive provide consent prior to the terminal withdrawal of life support obtaining surrogates consent to discontinue ECMO is of critical importance if we are to respect the autonomy of patients as expressed by their surrogates without such consent we risk return to old school determinism the response to this would be that our form first of all is not legally enforceable more and more I think the doctors have been using the form as a template for a discussion with families and rather than have a form that they have people sign the content of these forms what they really want to get across the families and so we view it really as an opening salvo if you will with surrogates alerting them to our inclination not to keep patients on such support when they are deemed not to be able to benefit we have at C1C we've never removed any life support device against the wishes of patients or surrogates and in the current document perhaps the Mayo Clinic terminology the permissibility of withdrawing that support is discussed should replace the device will be discontinued and it really isn't against the wishes that is the question arises also and the reason for the Finn's article is really is DNR appropriate to the ECMO? can a patient on ECMO ever die obviously just a rhetorical question what is the definition of death in a patient who remains on ECMO but has complete pulmonary failure and cessation of cardiac activity but they have continued circulation so here is the case of a 68 year old man who underwent aortic and mitral valve replacement and developed severe complications hours after the surgery the patient had a very high risk of 30 to 50% of an estimated operated mortality that's really outside the box he had underlying hep C liver disease portal hypertension, pulmonary hypertension and right heart dysfunction immediately following surgery he developed severe coagulopathy bleeding and required ECMO for right heart failure and pulmonary edema nobody ever dies in the OR or we have ECMO so the first post-op day the patient became acidotic pressers his cardiac function appeared to be negligible and he had no chance to survive but the family wanted continued aggressive treatment and they did not agree to do not attempt resuscitation the ICU attending Holman Ethics Consult regarding guidelines for attempting cardiac resuscitation how does one define death in this patient if his heart stops functioning entirely but circulation continues with ECMO is he dead if he develops B-fib or B-pac should he be shot is VA ECMO itself a form of continuous resuscitation obviating the ethical and medical need to attempt cardiac resuscitation in case of acystole fibrillation of the cardiac a family meeting was held with the other consultant and the ICU attending a detailed explanation of the patient's hopeless condition in the role of ECMO the family had difficulty accepting the hopeless prognosis in the face of optimism by the surgeon immediately post-op and what really got them to change their mind and say it's okay not to attempt resuscitation was the likelihood of this human brain damage because he had a prolonged arterial pressure of 30 and it was not the hopeless cardiac prognosis so how does one interpret a non do not attempt resuscitate precision by surrogates in a situation such as this with a patient fully dependent on ECMO and no chance of recovery this was in the ethics note might one consider that the family's wishes are in fact currently being granted as ECMO is a device that delivers cardiac resuscitation by replacing entirely the function of the patient's heart if and when the patient develops a flat line of cardiac tracing it would be inappropriate to attempt resuscitation as an attempt would be meaningless given the fact that continuous circulatory resuscitation is ongoing the flat line however will be of symbolic value to the family by indicating the absence of electrical activity of the heart superimposed on the already present absence of cardiac function and even if the family elected to continue ECMO it was expected that in a relatively short time either assistively brain death or collapse of whatever was left of circulation would occur in that case the ECMO would be discontinued the family did make the patient ENR the flat line cardiac arrest and ECMO would stop and I'll just skip over here to the response to the FENS article which basically said you shouldn't have to ask for DNR in the case of ECMO because it's an ongoing cardiac resuscitation I'll just summarize this because of time in fact we don't know at any given time how much contribution to the patient's circulation is being given by the patient's native heart so there is a role for DNR and patients on ECMO because at any one time the patient's heart may be contributing 20 or 30% to circulation and to say that all the circulation is being carried out by the ECMO machine really is an oversimplification so there is a role and in addition to that it also has a certain symbolic nature to DNR for the family saying we realize that our loved one is going to die we will not attempt to resuscitate the heart. I'm just going to finish with I saw this this morning and I think this brings it home as more of a human kind of thing the moral agonies of an ECMO nurse this is from a website called All Nurses this is what a nurse writes it is since taking on this new patient population that I have really been finding myself struggling morally and I don't know what my best personal course of action should be we mostly do VA ECMO and these patients arrive to us essentially dead sometimes the patients need to be on ECMO for as long as two to three weeks at which point regardless of level of stability sometimes the patients are on this whole time as well, chronic renal replacement therapy they are transitioned to an LVAD the patients usually TREP, PECTUBE is placed after the VAD and they wake up. I fear for the patients overall quality of life once they leave our unit it is not uncommon for this patient population to lose a limb or suffer trauma to their injuries from the ECMO placement I find it to be increasingly difficult for me to care for these patients I feel cynical over the situation and that family doesn't really understand what all of this new equipment entails my hands are tied as a bedside RN because I'm limited in what I can share with the family I'm wondering, all you ECMO nurses out there, do you involve ethics committee in all your cases or just certain ones I find our ECMO docs to be dreamers and statistic in their treatment options that they don't take a step back and think about the fact that this is a human life we are dealing with not just another percentage point maybe I'm too driven by faith and chance to be an effective bedside RN for ECMO patients I really love the complexity of the medical aspect but I'm having to force myself to not think of them as people in order to not feel heart broken over the numerous lifelong ailments we are potentially causing them I am ready to quit I need feedback people let me just tell you I don't know where this lady is a nurse at I can tell you that our ICU nurses who are among the best in the world they go from one extreme to the other they see people walk out of the hospital who five years ago ten years ago were surely dead young people who then can live the rest of their life and they see the opposite end of the extreme that this lady is discussing where you have no chance of support for patients getting abused so these technologies really do bring out all sorts of emotions and people and the caregivers as well I'll just skip to my conclusion you'll notice that I have over there this is a big sign in New York City on Fort Washington Avenue in the bridge between Milstein Hospital and Partners Pavilion and the logo for Columbia's amazing things are happening here people want to put a comment after amazing amazing but for the non for those of you who are not cynical amazing things actually do happen there and advancing medical technology we say many patients who want a short while ago with certain death but it creates ethical dilemmas for others who can't survive or who survive with major mental or physical disability or particularly sensitive employment for families, patients and caregivers being proactive by improving communication with patients and their families before the devices are employed discussing limitations as well as promises of such interventions it may mitigate the pain involved in many of the emotional and ethical issues that arise this is really an ongoing story all I can say is that as technology continues to evolve in your CPR patients that have cardiac arrest at the hospital or in the street and just think of the enormous ethical, moral resource issues that are going to be raised so I hope that I've been able to portray for you some of the odds that we as physicians and nurses feel as well as some of the good things as well I pointed out the bridge to nowhere we've had a lot of bridges to somewhere and I think that's what keeps us going thank you very much all the transplantation so I see these scenarios with great frequency in my discussion of these issues particularly when it looks as if the death is in fact on or off resuscitated efforts I like to have the conversation by saying that this is not a situation for discussing do not resuscitate but rather failure of resuscitation because they've already had everything that's available and I find that in my conversations with families that that is more easily accepted and say we're not going to do any more but rather that we've already done I think your point is extremely well taken I would only have and say that in New York State we have this law that basically says that we cannot withhold and attempt resuscitation without the consent of the family or the surrogates and I think framing it as you do we do with the echo cases that resuscitation is ongoing has already happened but nevertheless you have as in this particular case you have a family that they look at the oscilloscope they see the heart activity and as rational as your presentation may be they will not accept it and it's it's painful frankly I don't usually get too hung up with the DNR issue because I always tell the house staff when the people who are going to carry it out the law says you have to attempt it it does not say the duration, the aggressiveness that's a medical issue, that's up to you and so I'm not saying a slow code but I think that if they do a limited code because they say that's what's clearly indicated that's entirely justified immediately and everything. Thanks. I wanted to address a little bit about the withholding of the underlying distinction in general I really agree with what you've outlined in your own paper saying that if someone is already on the therapy that constitutes prima facie grounds to continue to be on the therapy if they desire it in a way that is different than if it wasn't started for them to begin with and you may know this came up in a very big way in terms of ventilators in the influenza pandemic situation where people were arguing and in fact I think the state New York State Task Force of Life law said that well if somebody is on it they've got a 30% chance of surviving and this other person has a 90% chance of surviving you can take the 30% person off and put the 90% person on which I think I find troubling. On the task force that's not quite what I'm expecting it wasn't the task force members of the task force were involved that's true it was a different task force but let me say though that I think let me push a little bit though if the prognosis is really zero do you think it's sensitive enough that you can get to a threshold where you would say the person can no longer have a claim on that resource vis-a-vis another person if the prognosis is zero and there are two people there's another person to get to that's a good question I think from an ethical point of view I think you can make a very strong case and take it off of that case I think the issue is purely on the family reaction and I God forbid that we have to get into that scenario frankly but as I say ethically I think it would be good if you have truly in the death situation somebody has been deprived of a life-saving resource I would take that off of that if we were ever in push came to shove I can see us doing that I'll give you a somewhat similar situation when we have brain dead patients in the neuro ICU at Columbia we have the state law says you have to have brain dead patients believed so if we have people who don't accept brain death there's death in New York state we have to accommodate their belief and the way we do it at Columbia is by keeping them on the bed and keeping the eyes of you going we don't attempt resuscitation we don't get blood tests and so on we stipulate in our hospital policy that and we will not therefore extubate the patient against the wishes if we have every bed in the neuro ICU filled and we have brain dead patients and we need that bed for a little person we will if necessarily extubate that patient or if we can't move them somewhere else we will extubate against the wishes of a family now you say well they're brain dead but they're not that according to the family's beliefs so in fact according to the family we're really killing them by taking them off it's the family distress but the scenario that you postulate I would take some more of that really? your two cases were two different scenarios in which ECMO is employed clinically one is a patient whose cardiac arrest is basically in the OR supportive therapy has clearly failed and ECMO is the only thing that may have a chance to be restored and the other was a situation where a patient was sort of electively placed on ECMO in a somewhat experimental fashion to see if they could bridge her further along to lung transplant do you think the ethics of the two situations are different first of all and then in particular in the second situation since there isn't a clear survival benefit associated with that therapy yet versus supportive care, special consent processes need to be undertaken given a situation you could get into like Ms. L. did where several complications of the therapy ultimately put her in this bridged to nowhere situation so let me understand first the first part of your question was do I think they are similar because of the different we called Ms. L. experimental I wouldn't call it experimental I would say it's by experimental we don't have the data perhaps yet to justify it in that sense you might say it we really don't we've already had so many successful cases that to us we're pretty but we've had patients who have kept alive the diagnosis of the transplant kept the transplant and let the hospital let the hospital it's sure I guess I'm in the sense that she wasn't eminently dying of hypoxic respiratory failure at the time it wasn't like you were putting on our back motor for dying of six hours she was slowly declining and you were trying to intervene extend her survival beyond support so does that make it a different ethical scenario than the man who was sort of near death and so forth I would say if you were going to ask the surgeon you know was his motive to prevent this patient from dying in the OR knowing full well that this man wasn't going to make it afterwards or was it because he felt there was still a reasonable chance that this patient might live the same way that the lady might get over her ECMO and then get a bridge to transplant I think if the intent in the case of the OR was to possibly save the life of this man not just unperforming put them on ECMO and then you can say that ethically they're quite similar you might question the clinical judgment of the surgeon and say are you, whether you're smoking you're putting this patient on ECMO and I think you have a strong case there but hypothetically if a person really feels that the surgeon really felt there was a legitimate chance for this person to survive I think that the ethical entitlement to ECMO in both cases Dr. Prager, thank you for that exhaustive treatise on ECMO I mean wonderfully done it certainly brings a lot of questions and a lot of answers to the forefront but we're privileged to have all this technology, ECMO, VADS mechanical development sort of devices, et cetera to help our patients and we want to continue to strive to maintain life in our patients and then point in life or the end of life when further therapy is futile then we have a discussion with the patient and with the family some of us are privileged to have that discussion ahead of time as you suggested to have that discussion ahead of time as to how long this therapy will continue but in the end, I think we as physicians we see that continuing this therapy whether it be simple or very complex really hangs on, you know, is this futile care and when it's futile care you have an end-of-life discussion with whoever is able to have that conversation with you, the family or the patient and then you withdraw care and I think whether it's ECMO or whether it's VADS or whether it's mechanical ventilation I think it all finals down the same pathway end-of-life discussion of futility and you withdraw care I always ask this question of folks in different institutions do you at your institution withdraw life support without consent or over the objection of patients or families you don't so you're basically making the theoretical justification for doing so but in fact, you don't do that is that right or did I misunderstand you I think well, I don't I don't know what the policy maybe but I don't do that but I have a conversation with the family and lead them down the pathway that if further care is futile and therefore we should be thinking of withdrawing and then give the family time sometimes it takes several conversations for them to accept that let me just point out the word futile over here can have different meanings for different people if the family comes to you and says you know what Dr. Prager you're saying it's futile but to me every second of life even though I know he's going to die here in the hospital every second of life is of infinite value I can come, I can see him, I can touch him I can listen even though he doesn't hear me and I want you to keep him alive as long as possible and I thank you for everything you've done and I know he's going to die here but I don't want you to remove him from life support because every second of life is of infinite value what is your answer to that yeah so we continue but then also we tell him that he will never recover his brain function will not recover that's okay that's not their goal their goal is to keep him alive per se the only argument that I think that you can muster against that which I don't use is that is this an appropriate use of medical resources I don't know of any other you can maybe bring up the moral the stress of nurses and doctors and so on but when a family we have families like this some have magical thinking and believe in miracles but we've had families who have been incredibly grateful to us after their loved one has been in the ICU for two months, decaying away, dying away on life support they thanked us for keeping him alive for the two months because they felt that every moment was precious I don't have a very good I had a young woman who once said to me a woman with severe brain damage her mother and ethics console and she said to me Dr. Frager I would grab her this is my mother in the hospital that was her words what's my rich word that's not my thinking not my thinking