Attending, Cardiac ICU Boston Children's HOspital BOSTON, Massachusetts, United States
Abstract: Introduction/Objective No publications quantify or characterize patient-level ethical issues in pediatric extracorporeal membrane oxygenation (ECMO) in the cardiac intensive care unit (CICU). We sought to examine characteristics associated with ethics consultation (EC) and document the ethical dilemmas referred to a hospital ethics consult service for pediatric ECMO patients in the CICU. Methods This is a single center retrospective study in a quaternary pediatric hospital using mixed methods. Local ECMO and ethics databases and records were cross referenced to include all patients on ECMO from 2012 through 2021 and identify those with EC. We compared demographic and clinical variables according to EC. We fit a receiver operating characteristics (ROC) curve to define optimal cutoffs for EC for run duration, length of stay (LOS) and sum of procedures or complications. To identify independent predictors of EC, we used forward stepwise selection in a multivariable logistic regression model including five a prior defined predictors. In the EC cohort, medical records and EC notes were thematically characterized into ethical themes according to two published frameworks; the Armstrong Clinical Ethics Coding System (ACECS) and a pediatric ECMO categorization (PEC). Results Of 349 ECMO patients, 22 received EC (6.3%). EC was associated with multiple ECMO runs, more complications/procedures, longer LOS and ECMO duration, decannulation outcomes and higher mortality (Table). Cutoffs for EC were LOS >52 days, run duration >158hrs and >6 procedures/complications. Independent associations with EC included LOS>52 days (adjusted odds ratio (aOR) 5.8, 95% CI [2.1, 16.1]), run >158hrs (aOR 4.0, 95%CI [1.4, 11.6]), and age (adjusted coefficient 1.3, 95%CI [1.0, 1.6]). The model showed good discrimination (area under the ROC curve 0.852) and fit (Hosmer Lemeshow test p = 0.723). The most common primary ethical theme per ACECS was end of life (Figure) and per PEC was ECMO discontinuation. Moral distress was cited as a significant ethical issue in 18 cases (81.8%). Conclusion We observed a low rate of EC compared to adult studies and the most frequent ethical themes were related to end-of-life care or ECMO discontinuation. Moral distress was also frequently identified. Older age, longer LOS, and prolonged ECMO runs were predictors for EC. This data may guide earlier identification of pediatric cardiac patients at risk for significant ethical issues and inform ethically supportable frameworks around ECMO. Future work should include model validation, quality improvement projects to improve EC utilization and evaluate the influence on patient experience and quality of care.
