The latest miracle machine of modern medicine (increasingly used) is called ECMO and can save people literally on the brink of death. I'm talking about people without functioning lungs, trapped underwater, or with stopped hearts.
What is ECMO medicine, the machine that puts death on standby? First of all, ECMO is not a convenient tool: for every person saved by ECMO (the acronym stands for Extracorporeal Membrane Oxygenation, in Italian Extracorporeal Membrane Oxygenation) there is one that dies despite its use.
ECMO is the most aggressive life support procedure, very expensive and demanding for the patients themselves: almost a trick against death. Indeed, to be honest: it is the exact opposite of the "death machines": in a certain sense it "tortures" the body to keep it alive. It pumps blood out of the body, oxygenates it and reintroduces it inside, keeping a person alive for days, weeks, months even with a stopped heart or lungs.
This machine created “a new paradigm,” according to Dr. Kenneth Prager, director of clinical ethics. “You can have a patient with a heart that no longer beats, but still keep him alive and awake thanks to the ecmo. You can put death on standby.”
Created to give life support to newborns, the ECMO is increasingly used also on adults. In the USA procedures have tripled in the last 4 years according to the Federal Health Research Agency.
ECMO is not designed as a solution to a problem (it is not) but as a bridge that saves the patient until recovery, recovery or transplant. But when patients are too sick, ECMO becomes just a very expensive (and cruel, in some ways) limbo that leaves them awake and conscious but with zero chance of survival without the machine. Doctors and family members only need to determine when to unplug and watch the patient end.
ECMO machinery: very high cost
Really. The average ecmo cost is around 600.000 euros per week. The heart-to-machine-price ratio is prohibitive. In a recent case, a hospital asked 4.5 million euros for less than 60 days of stay for a 19-year-old with a very serious respiratory syndrome, who remained in a coma awaiting a lung transplant that did not arrive.
The more widespread ecmo becomes, experts say, the greater the need to educate staff on whether or not to use it and on its correct use.
Four ECMO stories
The incredible stories (this is the tenor of all cases involving ECMO) of four patients can make us understand the possibilities and complexity of this technology.
Seven hours
The doctor Jessica Zitter she was on duty at the Oakland hospital in California when she was alerted by a code red. A 60-year-old patient with severe ventricular fibrillation that literally made him writhe with convulsions.
The staff performed a heart massage and an emergency tracheostomy to aid breathing. It didn't work. They applied the defibrillator and released two shocks. It didn't work. His oxygen levels were low. Someone was already arranging for the post-death cleaning of the "corpse". The team decided to try the use of ecmo, a real "blood recovery machine", requesting intervention from the University of San Francisco which sent the machine as soon as possible.
When the ECMO arrived, Dr. Zitter could do nothing but watch the procedure helplessly. One large tube was literally threaded into the patient's femoral artery, another into the femoral vein. When the blood began to escape from the body to pass through the respiratory ecmo the patient was almost black from deoxygenation. Just a minute later his complexion was back to normal.
Zitter, who has written essays on the excess of technology in an attempt to put death on standby and prolong survival, did not offer hope, however: the patient was already dead, he just didn't know it. He had waited seven hours, a good seven hours with his heart stopped waiting for the operation.
Imagine the shock of seeing the patient recovered and ready to be discharged.
“It was a crazy, crazy, crazy edge case with a crazy, crazy, crazy reaction,” is keen to specify. And he's right.
When patients undergo cardiac ECMO and respiratory ECMO at the same time, only one in three leaves the hospital alive. Higher rates are found in the case of respiratory operations - only the lungs (59%) or cardiac surgery - only the heart (42%).
The failure of Christmas
A more common case is like the one that happened to Dr. Haider Warraich of Duke University during his internship in cardiac surgery.
Warraich was called to the waiting room where a sixty-year-old awaiting a lung transplant had collapsed to the floor after a heart attack. The man, with white hair and beard, played Santa Claus in a theatrical comedy when a respiratory crisis made a lung transplant necessary.
His heart, short of oxygen, began to race wildly and not even the defibrillator solved the problem. Here too the practice of post-death cleaning was started and then interrupted. Motivated to save not only the man, but also the new lungs that would otherwise have been lost, the doctors requested ECMO therapy.
Once connected to the machine, the man's body was stabilized and an angioplasty was performed. No way. The kidneys were also in a critical stage, and nothing could restore a chance of survival. What was he like? Oh yes. Death on standby. After more than a month of limbo, the plug was pulled.
"In this case," says Warraich, “ECMO seemed appropriate. But doctors need more experience to understand when it is really useful and when it constitutes a form of obstinacy. Of course it is not easy, when a person is dying before your eyes, to decide clearly."
The technology, developed in the 70s, did not have encouraging results on adults until 2009, when the first positive results in the UK on patients with severe respiratory problems made her interesting.
The “desperate” treatment of swine fever subsequently justified (and widespread) the use of ECMO among adults. The average age of the first patients was 51 years, 10% over 65.
An intolerable choice
When a patient is on ECMO, the decision about when to end its use is always difficult and divisive among the medical staff, says Dr. Robert Truog, director of the Center for Bioethics at Harvard Medical School.
In one case illustrated in Lancet magazine, a 17-year-old arrived in the emergency room unit at Boston Children's Hospital, where Truog works as an intern. The boy, who had already undergone a lung transplant due to cystic fibrosis, was no longer breathing. The only way out was a pair of new lungs: he was placed on ECMO to keep him alive while waiting for a new transplant.
The boy was conscious, wrote to friends, did some remote work, received visits from relatives. After two months of "artificial" life, yet another blow: he was diagnosed with inoperable cancer, which made him no longer eligible to receive new lungs.
Doctors were divided at this point over what to do, Truog says. Some wanted to immediately disconnect the respiratory ECMO to make room for other patients who still had a chance. Others refused, knowing full well that detachment from the machines would lead to the immediate death of a patient who for the moment had a good quality of life.
A real moral dilemma.
For the relatives, the choice of a moment to turn off the ECMO medicine when their relative was still alive and conscious, knowing that he would die instantly, was intolerable.
In the end the doctors chose a solution shared with the relatives: they did not replace the ECMO membrane oxygenator, a part that had to be replaced every two weeks to avoid blood clots. After about ten days, the machine slowly lost its effectiveness and the patient lost consciousness, dying shortly after.
The solution once again allowed death to be put on standby. To be precise, it allowed to choose an unspecified time of death. But it was still atrocious.
The long goodbye
Karen Ayoub had never heard of ECMO until her husband was forced to use it.
Philip Ayoub, 58, was a man of great charisma, a lover of the family: the couple had twins and lived in Greenwich, Connecticut. A congenital and family heart problem forced him to his first bypass at the age of 30, with a second surgery just 13 years later.
In December 2017 he underwent a third bypass operation but things went badly: his heart was weaker than expected. He lost consciousness and was rushed to Columbia University Medical Center, which was equipped with a medical ECMO.
Karen Ayoub said putting her husband on the ECMO machine was an easy decision: "I thought he deserved every chance of survival." But she didn't know how she would react.
When her husband regained consciousness he said: “Why am I here?”. She remained in intensive care for two months: a feeding tube, a breathing tube, ECMO medicine and dialysis.
ECMO, it was not in vain
He began to suffer from post-traumatic stress disorder, night panic and other physical and psychological side effects. Meanwhile, all the treatment options explored proved impractical, and it soon became clear that Philip's procured agony would be useless.
Yet Karen considers it a beautiful gift to have been able to spend more time with her husband, albeit little. And Philip did not pass a single day, even in great suffering, without repeating constantly “I will always love you, I will always be with you” to his wife and children.
When Karen told Philip that she had decided to stop life support, Philip was not afraid. He told her “I can't wait to know what's next.” They sedated him, hugged him and watched until the end.
ECMO a “useless” treatment
While the Ayoub family faced fate with heartwarming courage, other families are by no means ready to let a loved one go.
Some patients in ECMO medicine have severe and irreversible brain damage. They are in no condition to participate in decisions about their lives, and in fact have no hope of leaving the hospital alive.
For them, several palliative curia experts write, ECMO represents "the most extreme form of medical uselessness". They say doctors should have the authority to end life support in cases like these, even if against the opinion of families. Ok death on standby, but there is a limit to everything.
The law is involved, however. “In the US there are states like Idaho, Oklahoma and New York that do not allow doctors to turn off ECMO without the consent of patients or family members,” says Thaddeus Mason Pope, director of the Health Law Institute at the Mitchell Hamline School of Law in St. Paul, Minnesota. In other states such as California, Texas and Virginia, doctors can proceed without consent.
Ethical limits of the ECMO
Doctor Robert Bartlett, a true pioneer in the field of ECMO and professor emeritus at the University of Michigan, says that when ECMO becomes a hopeless limbo, the family must be notified and made clear that the time has come. “It is painful and rude to place the responsibility on the family for a choice that does not exist,” He says.
Several hospitals are preparing to take advantage of these short waiting periods before a detachment to help families deal with it and accept it.
Because if there is a moral behind the promises and limitations of a "miracle machine" like ECMO medicine, it is that miracles do not exist. Any advanced device for health of the future it will always carry a gigantic load of expectations and hope. The challenge is to temper this hope with reality, so that it is clear that every innovation presents new answers, but also new ethical questions that make us grow technologically, emotionally and spiritually.
