CHEST Guidelines-COUNTERPOINT--Should-Patients-With-Advanced-Lung-D (1)

COUNTERPOINT--Should-Patients-With-Advanced-Lung-D (1)

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The discussion centers around the use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation for patients with advanced lung disease who have not yet been listed for transplant. Drs. Whitney Warren, Robert Walter, and Phillip Mason argue against offering ECMO to these patients, pointing out several concerns.<br /><br />Firstly, they highlight that ECMO outcomes are significantly better in high-volume centers with extensive experience and caution that other centers may have poorer outcomes, evidenced by lower 1-year survival rates. Many transplant centers perform fewer than 35 transplants annually, suggesting that most facilities do not have the requisite experience to effectively use ECMO as a bridge.<br /><br />Secondly, they raise the "bridge to nowhere" concern, where patients who are not yet listed for transplant may be sustained by ECMO without ever receiving a transplant, leading to ethical and emotional dilemmas. Once patients are on ECMO and not considered candidates for transplantation, decision-making about discontinuing ECMO can become ethically complicated and emotionally taxing for medical staff and families alike.<br /><br />Moreover, they consider the potential impact on patient assessment, worrying that emotional bonds formed with ECMO patients could lead to biased listing decisions, which might skew organ allocation priorities and patient outcomes.<br /><br />In contrast, Ms. Gannon and Drs. Stokes and Bacchetta acknowledge these challenges but argue that with standardized decision pathways and a thoughtful care approach, ECMO can be offered in certain circumstances. They emphasize that avoiding ECMO due to potential ethical issues may not do justice to patients who might benefit from advanced therapies. They assert that emotional bonds should not prevent teams from making objective decisions, as transplant candidacy is determined through collective decision-making, not individual preference.<br /><br />Overall, the consensus is cautious about widespread use of ECMO for patients not yet listed for transplant, advocating for its use primarily at centers with sufficient experience and resources.

Keywords

ECMO

lung transplantation

advanced lung disease

high-volume centers

ethical dilemmas

patient outcomes

organ allocation

standardized decision pathways

transplant candidacy

collective decision-making