**6. Nursing implications in ethics and ECMO withdrawal**

With the advent of advancing ECMO technology comes an expanded library for indications of use. VA and VV support are commonly being utilized for bridge-totransplant and respiratory or cardiac failure. Additionally, ECMO therapy is being utilized as bridge to support the body through a medical emergency in the form of extracorporeal cardiopulmonary resuscitation (ECPR). With the introduction of high-tech innovation, critical care nursing frequently encounters stressors due to resource scarcity, increased workloads, and moral distress related to carrying out aggressive life-sustaining treatments that may conflict with the patient's best interests or maybe even personal preferences.

ECMO is a costly, resource-intensive therapy requiring commitment from the patient, family, and multiple disciplines. The impact of caring for an ECMO patient puts a mental and physical strain, not only on the patient and family but the entire medical team involved in the patient's care. Providing the intense, complex nursing care impacts not only the nursing staff or ECMO provider but the entire nursing unit caring for the patient. Institutions employing the use of ECMO in treating complex, critically ill patients as one of their only means of survival must have a process that addresses the moral and ethical dilemmas that arise from caring for the critically ill. Common questions are "Who receives ECMO treatment?", "When should support cease?", and "What is the goal of therapy, *quantity* or *quality* of life?"

Allocation of nursing resources has become undoubtedly one of the most challenging aspects in caring for patients and families. Nursing staff ratios, complexity of patients, and the mental and physical impact on the bedside nurse become compounded when one critically ill patient draws a majority of a unit's resources. ECMO patients can begin their treatment with significantly unstable hemodynamic parameters requiring multiple blood transfusions, circulatory support with several vasoactive medications, and frequent lab draws pulling a majority of the nursing unit's resources for the care of one patient. This places an enormous burden on the nursing staff to be creative and flexible with patient care assignments. RN:patient ratios may be less than desirable, ultimately impacting the care provided to other patients on the unit as well. Everyone, from the unit manger to housekeeping, plays a hands-on role in supporting the entire unit as well as the ECMO care team.

How do we reduce some of the ethical or moral dilemmas nurses experience caring for complex, critically ill patients? Communication is the key in healthcare. An integral part of communication is developing and maintaining a team not isolated to healthcare workers but also including the patient and family. Early involvement of the palliative care team and social work is crucial to providing consistent support to the patient and family. Interdisciplinary daily rounds including the bedside nurse,

family members, palliative care team, and social work are integral to find commonalities for all regarding goals of care. If conflict arises about treatment benefits or burden and the patient's best interest is no longer being served, support from the ethics committee can be beneficial to the family and healthcare team. These are just the foundation. In critical care nursing, it is important that the nursing staff's voice be heard. It is vital to recognize the nursing assessment of not just the patient but the situation and to be included in the decision-making that nurses are ultimately responsible for performing.

#### **6.1 Withdrawal of ECMO therapy**

Unfortunately, despite a team's best efforts, an ECMO patient may continue to decline, with multiple organ systems failing or a devastating systemic event. In such cases, withdrawing care may be imminent, and the question must be asked of the patient and family should be "is the patient's preference *quantity* or *quality* of life?" Can the patient make their wishes known? In the case of bridge-to-transplant, patients may be able to make their wishes known to their families and healthcare team. For the critically ill patient who is dependent on their family or the healthcare team for their medical decisions, is this truly representative of what the patient's wishes would be? Does conflict arise between the healthcare team and family regarding withdrawal of care? These questions are applicable in any situation involving ECMO; however, they cannot be answered algorithmically or methodically, as they need to be answered uniquely to each situation.

Nurses are in a unique position in healthcare. They are at the bedside for 8- or 12-hour shifts as most consistent patient advocate. They support and inform family members and build personal and emotional bonds with them. Although valuable, this rapport can be morally taxing to the bedside RN. As nurses witness a patient and families suffering during clinical decline, they begin to question the continued aggressiveness of care that likely will not benefit from treatment, thus causing moral distress to the nursing staff. Sadness, frustration, and anxiety felt by the nursing staff for prolonged periods of time can lead to staff burnout, job dissatisfaction, and decreased staff retention.

### **7. Conclusion**

The ECMO patient is often the most critically ill within the hospital at any given moment, prompting highly trained bedside RNs as well as other healthcare providers, familiar with the therapy, to be readily available to provide the multifaceted care this population requires. In addition to routine ICU care, the ECMO patient necessitates additional monitoring due to associated risk factors assumed when being placed on pump. Medical, ethical, and emotional considerations exist and must be addressed regularly in order to provide the best care of this unique patient population. Despite high mortality associated with ECMO, the survivability continues to increase as time progresses and the bedside RN will continue to be responsible for vital functions in continuing that trend.

**23**

**Author details**

provided the original work is properly cited.

Summa Health, Akron, Ohio, United States

*Nursing Implications in the ECMO Patient DOI: http://dx.doi.org/10.5772/intechopen.85982*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Alex Botsch\*, Elizabeth Protain, Amanda R. Smith and Ryan Szilagyi

\*Address all correspondence to: alexander.botsch@gmail.com

*Nursing Implications in the ECMO Patient DOI: http://dx.doi.org/10.5772/intechopen.85982*

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

responsible for performing.

**6.1 Withdrawal of ECMO therapy**

faction, and decreased staff retention.

**7. Conclusion**

family members, palliative care team, and social work are integral to find commonalities for all regarding goals of care. If conflict arises about treatment benefits or burden and the patient's best interest is no longer being served, support from the ethics committee can be beneficial to the family and healthcare team. These are just the foundation. In critical care nursing, it is important that the nursing staff's voice be heard. It is vital to recognize the nursing assessment of not just the patient but the situation and to be included in the decision-making that nurses are ultimately

Unfortunately, despite a team's best efforts, an ECMO patient may continue to decline, with multiple organ systems failing or a devastating systemic event. In such cases, withdrawing care may be imminent, and the question must be asked of the patient and family should be "is the patient's preference *quantity* or *quality* of life?" Can the patient make their wishes known? In the case of bridge-to-transplant, patients may be able to make their wishes known to their families and healthcare team. For the critically ill patient who is dependent on their family or the healthcare team for their medical decisions, is this truly representative of what the patient's wishes would be? Does conflict arise between the healthcare team and family regarding withdrawal of care? These questions are applicable in any situation involving ECMO; however, they cannot be answered algorithmically or methodi-

Nurses are in a unique position in healthcare. They are at the bedside for 8- or 12-hour shifts as most consistent patient advocate. They support and inform family members and build personal and emotional bonds with them. Although valuable, this rapport can be morally taxing to the bedside RN. As nurses witness a patient and families suffering during clinical decline, they begin to question the continued aggressiveness of care that likely will not benefit from treatment, thus causing moral distress to the nursing staff. Sadness, frustration, and anxiety felt by the nursing staff for prolonged periods of time can lead to staff burnout, job dissatis-

The ECMO patient is often the most critically ill within the hospital at any given moment, prompting highly trained bedside RNs as well as other healthcare providers, familiar with the therapy, to be readily available to provide the multifaceted care this population requires. In addition to routine ICU care, the ECMO patient necessitates additional monitoring due to associated risk factors assumed when being placed on pump. Medical, ethical, and emotional considerations exist and must be addressed regularly in order to provide the best care of this unique patient population. Despite high mortality associated with ECMO, the survivability continues to increase as time progresses and the bedside RN will continue to be

cally, as they need to be answered uniquely to each situation.

responsible for vital functions in continuing that trend.

**22**
