Palliative care

• Often physician or advance practice nurses

Hospital leadership and administration


It is critical that even with dedicated, hardworking, and engaged clinical teams, there must be support and encouragement from hospital leadership and administration (**Figure 1**) [7].

Many of the chapters in these volumes discuss the various indications for ECMO (veno-venous and venoarterial) support and special patient populations and circumstances. However, a critical component of any program remains the role of striving for optimal clinical outcomes. Regardless of the indications and populations, outcomes and clinical complications (e.g., renal failure, limb complications,

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

#### **Figure 1.**

*ECMO "team". Adopted from reference intro chapter in Volume 1 [1].*

transfusion rates, etc.) must be tracked and compared to published benchmarks. Quality conferences in which cases are discussed can help a team and program formally recognize their successes while looking for opportunities for collective improvement. As discussed previously in the introductions (and various chapters) of the previous volumes, outcomes still remain less than ideal with survival rates that range from 60 to 70% for veno-venous respiratory support and 25–35% for venoarterial cardiopulmonary support and eCPR [8, 9]. These less-than-ideal success rates should improve over time as programs gain experience and implement guidelines and protocols, teams learn to function more effectively and efficiently, and patient selection and management improve. However, poor outcomes must also be tempered by the concerns that outcomes that are potentially "too good" might suggest that potentially salvageable but higher risk patients might not be offered therapy out of fear of experiencing a bad outcome. Nevertheless, it becomes the priority of a program to develop a "culture" of how aggressive they want to be with regard to offering therapy to high-risk (or low-risk) patients. Fortunately, scoring systems for venoarterial and veno-venous support indications can assist in patient selection. Again, outcomes and quality metrics must be benchmarked against similar programs, like institutions and established registries. Membership in the Extracorporeal Life Support Organization (ELSO: https://www.elso.org) is an important component of tracking outcomes and can play a key role in documenting program progress and success. In addition, membership can provide an opportunity to establish relationships with other programs to exchange ideas, share protocols, and have access to important and timely developments and technological innovations.

While the advances in the field of ECMO are rapid and there has been an equally rapid worldwide growth in programs and the number of patients supported, a key aspect of ECMO therapy is the ethical component of a highly invasive, resourceintensive, and complex intervention. Because ECMO is still associated with less than ideal outcomes, relatively high complication rates (including neurologic complications), and high resource intensivity (not to mention expensive, depending on the reimbursement circumstances which can vary dramatically), a fundamental question remains regarding not on whether we can offer and continue support, but

**7**

**Figure 2.**

*Introductory Chapter: ECMO – Rapidly Evolving Technology, Expanding Indications…*

within an ethical and moral framework should we offer support. The chapter by Dr. Aultman on the ethics of ECMO therapy explores many of the difficult decisions and circumstances that providers often face when considering offering or continuing therapy in patients who would most likely immediately die if support is neither

Experiences in the selection and management of patients with acute cardiac and respiratory failure who are treated with ECMO continue to grow. Recent trials continue to help demonstrate the effectiveness and role of ECMO as outcomes continue to slowly improve [10, 11]. Even though many patients treated with ECMO still die even in the best of circumstances, it remains important for everyone to continue to search for opportunities for improvement. Good outcomes must be embraced and shared with the entire team, as they can provide hope while also inspiring and motivating a team—even when there are concerns of futility (**Figure 2**). The goal of this volume is to offer further insights, experiences, and discussions of the current state of the art regarding many topics that challenge those who believed in the

*BH (center in wheelchair) with his parents after qualifying for the finals in the single-scull, arms and shoulder only, rowing competition in the 2016 Paralympics in Rio de Janeiro. BH, a five-time US national champion in the event, represented the USA in Rio as a member of the Olympic team. In 2016, he was selected US rowing "rower of the year." several years prior, BH lost both legs to complications of a necrotizing soft tissue infection and required cardiopulmonary support with venoarterial ECMO due to overwhelming septic shock. Picture* 

*used by permission by all represented [11, 12] and adopted from volume 2 [13].*

*DOI: http://dx.doi.org/10.5772/intechopen.89475*

tremendous potential benefits of ECMO [12].

offered nor continued.

**2. Conclusions**

*Introductory Chapter: ECMO – Rapidly Evolving Technology, Expanding Indications… DOI: http://dx.doi.org/10.5772/intechopen.89475*

within an ethical and moral framework should we offer support. The chapter by Dr. Aultman on the ethics of ECMO therapy explores many of the difficult decisions and circumstances that providers often face when considering offering or continuing therapy in patients who would most likely immediately die if support is neither offered nor continued.
