Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: Ethical considerations

Out-of-hospital cardiac arrest (OHCA) continues to be a leading cause of mortality worldwide. In Canada over 40,000 cardiac arrests that occur each year, a majority occur unexpectedly outside of the hospital setting. However, the reality is that without rapid and appropriate treatment within minutes, most victims will die before reaching the hospital. In the late 1980s case reports identifying favorable outcomes with the use of extracorporeal cardiopulmonary resuscitation (eCPR) in out-of-hospital cardiac arrest (OHCA) began to be reported. Since then case reports, observational studies, propensity analysis, and a systematic review of international practices continues to suggest eCPR as a feasible intervention for refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in select adult patients. However, in spite of this mounting base of evidence, clinicians continue to report concerns over a paucity of robust data showing definitive eCPR effectiveness compared with conventional resuscitation. This review will explore the ethical issues related to the impact eCPR might have on the orthodoxy pertaining to current resuscitation strategies, the impact of shifting decision-making on families particularly in dealing with a "bridge to nowhere" scenario, a call to accounting for greater data integrity and improved outcome reporting to assess eCPR effectiveness, and addressing the "Should we just do it" question. A recommendation is proposed for the creation of an ethics consultation service to assist families and staff in dealing with the invariable value conflicts and stresses likely to arise.