CHEST Guidelines-Rebuttal-From-Ms-Gannon-and-Drs-Stokes-and-Bacchet (1)

Rebuttal-From-Ms-Gannon-and-Drs-Stokes-and-Bacchet (1)

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The document debates the use of extracorporeal membrane oxygenation (ECMO) as a bridge to decision (BTD) for patients with end-stage lung disease (ESLD) who are not yet listed for a transplant. The primary argument against using ECMO-BTD is that it should only be offered at high-volume ECMO/transplant centers due to better outcomes linked to expertise and volume. Critics argue that these systems can be labeled as the "bridge to nowhere" due to emotional, ethical, and practical complications. <br /><br />The rebuвАдв retorts that withholding ECMO-BTD is against the ethos of transplantation since it might deny patients potentially life-saving interventions. The authors propose a careful and standardized decision-making pathway, suggesting that emotional bonds formed between clinicians and patients should be managed with support mechanisms rather than avoiding ECMO-BTD entirely.<br /><br />The counter-rebuttal highlights several weaknesses in offering ECMO-BTD. Key points include that expert opinion generally does not support ECMO as a bridge to transplant evaluation (BTTE); patients meeting the criteria for ECMO-BTTE are rare; and logistical challenges exist, like the limited number of high-volume centers. The scarcity of such centers means that most patients do not meet the criteria for BTTE, emphasizing the need for early referral to transplant centers. Additionally, the first-step recommendation that patients should be at an expert center before getting ECMO might be impractical due to the limited number of such centers, suggesting ECMO-BTTE may not be widely feasible.<br /><br />Both sides underscore the importance of early referral to transplant centers, but while one side views ECMO-BTD as a viable interim solution, the other argues it may increase emotional and ethical burdens without substantially improving outcomes. The debate underscores complex considerations in balancing ethical obligations with practical and emotional challenges in treating ESLD patients.

Keywords

ECMO

bridge to decision

end-stage lung disease

transplant centers

ethical challenges

expert opinion

early referral

emotional bonds

logistical challenges

life-saving interventions