CHEST Guidelines-The-Need-and-Approach-for-Critical-Assessment-of-E

The-Need-and-Approach-for-Critical-Assessment-of-E

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The commentary by Jonah Rubin, MD, and Eddy Fan, MD, PhD, discusses the urgent need for standardized and fair decision-making processes in the selection of candidates for extracorporeal membrane oxygenation (ECMO). As ECMO usage rises, inconsistencies in candidate selection across different institutions and over time have emerged, raising ethical, clinical, and systemic concerns. The variability can be attributed to factors such as institutional experience and resource availability, which may introduce subjective biases into what should be an objective decision-making process.<br /><br />The authors highlight that published guidelines often struggle to keep pace with evolving clinical data, resulting in mixed messages about contraindications such as age and body mass index (BMI). These inconsistencies can lead to unconscious biases in treatment decisions and inequities, as observed in other medical contexts like left ventricular assist device implantation and organ transplantation.<br /><br />To address these issues, the authors propose that institutions should focus on achieving internal consistency in ECMO candidacy decisions. This would involve rigorous data collection on all ECMO-related decisions, including those patients declined as candidates. A standardized data collection system, potentially incorporating survey-based tools, could enable tracking and analysis of decision-making processes. This, in turn, could detect biases and encourage equitable practices.<br /><br />Additionally, pooling data from multiple institutions could allow for a broader comparative analysis to identify systemic discrepancies and inform multicenter research. Until standardized global guidelines for ECMO candidacy are available, creating a referral system to direct patients to the most appropriate centers could be beneficial.<br /><br />Finally, the authors are piloting a data collection process across several institutions for venovenous ECMO, aiming to enhance equity and reduce disparities, thereby fulfilling their responsibility to continually reassess and improve clinical practices.

Keywords

ECMO

standardization

decision-making

institutional variability

ethical concerns

clinical guidelines

bias detection

data collection

equity

multicenter research