173: Beyond the Bridge: ECMO as Destination Therapy

ECMO is broadly conceived as only a bridge, whether bridge to recovery, bridge to transplant, bridge to device, or bridge to decision.[1] When none of these bridges is possible, some describe ECMO, perhaps insensitively, as a so-called “bridge to nowhere.”[2] In such situations, patient life is indefinitely limited to the ICU and discontinuation of ECMO is recommended.[3] We challenge this perspective and defend continuation of ECMO as destination therapy (ECMO-DT), if in accordance with the (presumed) patient’s will. Because ECMO-DT fulfils its intended physiologic goal (blood oxygenation and CO2 removal), it is not futile, and treatments should not be terminated unilaterally against the will of patients or family.[4] One major argument against ECMO-DT is that patients on ECMO cannot survive outside the ICU, so cannot have a meaningful life. But despite this traditional understanding and despite the original intent to use ECMO as bridge-only, such resolute immutability is incongruous and unacceptable. Analogous therapies like RRT, LVAD and mechanical ventilation all originated as bridges. But they evolved to become “destination” therapies. It is time for ECMO to evolve similarly from bridge to destination therapy. Even if less desirable than the original destination, many patients prefer technology-supported life to death. References 1. DOI: 10.1378/chest.13-1138 2. DOI: 10.1080/15265161.2023.2201196 3. DOI: 10.1097/MAT.0000000000001432 4. DOI: 10.1164/rccm.201505-0924ST