An extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique used in intensive care medicine that provides both cardiac and respiratory support oxygen to patients whose heart and lungs are so severely diseased that they can no longer serve their function. To initiate ECMO, cannulae are placed in large blood vessels to provide access to the patient’s blood. Anticoagulant drugs, usually heparin, are given to prevent blood clotting, as the ECMO machine continuously pumps blood from the patient through a “membrane oxygenator” that imitates the gas exchange process of the lungs. The machine removes carbon dioxide and adds oxygen, in which the oxygenated blood is then returned to the patient. There are several forms of ECMO, the two most common of which are veno-arterial (VA) and veno-venous (VV). Both modalities oxygenate blood drained from the venous system outside of the body. In VA ECMO, this blood is returned to the arterial system and in VV ECMO the blood is returned to the venous system and no cardiac support is provided. VV ECMO can provide sufficient oxygenation for several weeks, which allows the diseased lungs to heal while the potential additional injury of aggressive mechanical ventilation is avoided.

Therefore, ECMO may be life-saving for some patients. However, due to the high technical demands, cost, and risk of complications, ECMO is usually only considered a last resort therapy. ECMO is most commonly used in the Neonatal Intensive Care Units (NICU), for newborns in pulmonary distress. The machine is around 75% effective in saving the newborn’s life. Newborns cannot be placed on ECMO if they are under 4 and a half pounds, therefore, ruling out the device for most premature newborns. Newborn infants are occasionally placed on ECMO due to the lack of a fully functioning respiratory system or other birth defect, but the survival rates drop to approximately 33%. Typically newborns remain on ECMO for three to seven days, with the average time limit for a newborn is usually around a 21 day maximum. Once the baby is off ECMO, they will still need a ventilator for a few days or weeks (Wikipedia, 2008).

Having a conscious, critically ill newborn hooked up or withdrawn from an ECMO is especially difficult for a nurse specialist in the NICU. Unlike adults in the intensive care unit, newborns are not able to communicate in any way with their family or physician for the most part. Adults often may show cognition by mouthing or writing words and making requests, however, newborns have not yet developed these skills yet. Obviously the NICU nurse specialist, along with physicians, and family make the decision to put the newborn on ECMO. However, the determination of when to stop ECMO rests upon demonstration of the return of adequate cardiac function to support vital organs and permit subsequent recovery. When weaning a newborn off of ECMO support due to a heart condition, if the weaning is not successful and additional time does not lead to adequate recovery of cardiac function, the nurse and physician must be prepared to realistically advise families regarding such options as cardiac transplantation or withdrawal of support. It is critically important to provide an open and nonjudgmental environment for families to make these difficult decisions. The greatest difficulty involve the ethical and emotional decisions that need to made in a timely fashion by the NICU nurses, besides the family, mainly because of their close, strong interaction with the newborn patient and families (Blackwell-Synergy, 1999).

Another huge source of distress and hardships for NICU nurses and other clinicians alike is confliction with the family about the decision to place and withdraw the newborn on ECMO support. Unfortunately, NICU nurses can be viewed by families, community, and colleagues as merchants of death. Conflict about end of life issues is extremely common in the health care field. Family members because of their close attachment with their newborn patient often have a difficult time remaining objective about the specific prognosis.

It is important to remember that the family members and other clinicians may all be going through the different stages of the grieving process, as they all consider the fact that this critically ill newborn patient has not even had the chance to experience life. The stages of the grieving process include: denial, anger, bargaining, depression, and acceptance. Most families, and particularly some NICU nurses, take a considerable amount of time to reach the acceptance stage in the grieving process. However, clinicians and nurses tend to reach the acceptance stage much quicker because of their constant occupational exposure to death.

Repetitive research has showed that the best way to solve conflicts with family members is to most importantly understand the situation and communication. Families, especially parents of a newborn baby, are going through a difficult time and experience a roller coaster of mixed emotions. Again, communication plays an important role is reducing conflicts among family. The most common approach as a NICU nurse is to educate and negotiate with family members about conflicts that may arise around decision making, while also consoling them as well. Families often disagree about treatment plans because they are either misinformed of the disease and treatment, or do not fully understand them. Once the newborn patient’s prognosis and treatment plan have been properly explained, this may resolve many disputes on the delivery of care. NICU nurses and clinicians often have to realize that futile care has to be explained to families before they can realize that some therapies must be abandoned or never started for the good of the patient (Keene, 2007).

For NICU nurses to handle a newborn baby on ECMO support, they require the full support of the hospital to properly handle the whole process from an emotional, professional, and psychological stand point. New graduates or nurses that perhaps are new to the NICU should not be expected to handle dealing with an ECMO patient on their own. This would be too much stress and pressure for someone just entering the field to be expected to handle without the support of a veteran NICU nurse or physician to answer questions and provide advisement. Proper meetings and discussions are good ways to have open communication and personal opinion for the entire clinical team involved. This effective communication also provides an opportunity to discuss any opportunities for improvement in future ECMO newborn patients. All clinical members should have access to counseling services provided by the hospital. It is also not suggested for a NICU specialty nurse not to perform or deal with concurrent ECMO newborn patients (Keene, 2007).

Clinical decision support systems (CDSS) are computer-based information systems used to integrate clinical and patient information to provide support for decision-making in patient care. They may be useful in aiding the diagnostic process, the generation of alerts and reminders, therapy critiquing and planning, information retrieval, and image recognition and interpretation. This is another way that support systems can be viewed as a major role among nurses and other clinicians (Tan, Dear, Newell, 2005).

With the hopes of easily suffering and helping patients get well is how all health care clinicians enter the field of medicine. Nurses are trained to treat all patients with the best care possible under circumstance. The nursing theory seeks a collaborative relationship with the person in their care. It therefore emphasizes autonomy of the person being nursed over paternalistic practice where the health professional seeks to do what they believe to be in the individual’s or societys best interests. Codes of conduct for nurses tend to be based on the rights of the patient and the duties of the nurse rather than on utilitarian concerns of the consequences justifying the action. Therefore, when a nurse is faced with the issue of taking a patient off of the ECMO support, it goes against everything that the nursing field teaches, which is to do whatever it takes to keep the patient alive. The concept of non-maleficence is embodied by the phrase, “first, do no harm.” Nurses are obligated under medical ethics to not provide medications or actions they know to be harmful. However, particularly in the neonatal intensive care unit, nurses violate non-maleficence when they might have to remove the life support system. When both beneficence and non-maleficence is violated, many nurses struggle with this and indeed they should. It is extremely difficult to switch modes for a nurse from providing every means of life support to a patient during a code who if they survive will most likely require some form of life support, to then turn around and have to terminate assistive support on another patient requiring ECMO. (Wikipedia, 2008)

The hard concept for clinicians to accept when dealing with end of life care management is the principle of respect for patient autonomy. It is very hard for most neonatal nurses to accept that sometimes parents choose death over a commitment to ECMO, and are therefore called upon to assist in the terminal weaning procedure. This is a perfect example of where patient autonomy comes in direct conflict with the nurse’s obligatory duty of beneficence and non-malficence. Autonomy has become more important as social values have shifted to define medical quality in terms of outcomes that are important to the patient rather than medical professionals. This can also become a major conflict when nurses have to discuss with the parents in NICU the recommendations that are believed to be in the patient’s best interest, because the parents may not agree. The nurse must weigh their duty of care against the autonomy of the person in care. Sometimes it is extremely difficult for a nurse to suppress their heroic instincts and respect patient’s wishes. (Code of Ethics, 2008)

The perceived quality of life for each individual is subjective and unique to that particular individual. For example, one person or parent may find that living with severe brain damage and having to rely on caregivers acceptable and may proceed on to lead a fulfilling life. However, another person or parent may face the same situation and find this quality of life to be unacceptable and decide that continuing life for the patient is undesirable. In the NICU, parents often come to the realization once the treatment plan and prognosis for their baby has been explained that there perceived quality of life is not worthy of continuing and elect to refuse to continue life sustaining measures. A portion of these life prolonging procedures that parents decide to terminate involved ECMO. Nurses discuss with the parents and can only determine if they were the patient would they choose to be terminally weaned. Once again the quality of life is highly subjective and individualized so it is likely that different people in a given situation will come to different conclusions for different reasons. Nurses witness an ethical dilemma if the parent chooses to terminally wean their baby even though they feel as if they could still yield a good quality of life. (Keene, 2007)

When it has been decided that a patient must be terminally weaned off the ECMO, nurses often find themselves in conflict with their personal religious beliefs. Although the nurse is not euthanizing a patient, they are removing equipment that will most likely always lead to death. Some nurses feel that in order to fully complete their job functions that they are forced to put aside and betray their religious beliefs. Stress is also added to nurses and brings up ethical questions about the facility and the health care system in general, when patients either can’t afford ECMO or there is a shortage or no ECMO machines available. (Wikipedia, 2008)