There's a FANTASTIC ethnography of ECMO in press @AnnalsofSurgery with 380 hours of observations and 47 interviews with families and clinicians of 20 #ecmo patients. There are A LOT of parallels to mechanical ventilation in the #ICU.

@ATSEthicsCOI #CriticalCare #MedTwitter

Phase I of ECMO: Was there ever really a choice? When the options are "miracle" vs "lay there and die" why are we even asking? (besides being legally required)

Phase II: The clinical team believes they own the patient's body. They escalate care until they feel they've hit the "care ceiling" and there's nothing left to do.

During phase II, if a family member expresses skepticism or doubt they are reassured. The clinical team assumes that all families wish to escalate until the care ceiling is reached but are too ignorant to know where the ceiling lies.

Phase III: The care ceiling
This is a really awkward phase where the clinical team knows the patient will die, but an obligatory 2-3 days pass in the hopes the family will figure it out without anyone explicitly telling them.
*This is where moral distress is off the charts.*

Finally, the clinical team discloses the care ceiling and requires the family to take responsibility for the ultimate decision to stop treatment.
The family refuses.
Ultimately, a compromise is reached - the patients' physiology has decided. No one is responsible for the death.

This process repeats itself in so many medical settings.

I'm tired of witnessing it. I'm tired of its cruelty.

I'm tired of hearing that alternatives to this pathway are possible if families just speak up.

I'm tired of pretending that these decisions are "shared."