Ethical guidance for extracorporeal and paracorporeal device use in children: a systematic review

Background To provide substantive, practical guidance on the ethical use of pediatric extra/paracorporeal devices, we first need a comprehensive understanding of existing guidance. The objective was to characterize how ethical guidance for device use in children is provided in published literature and to summarize quantity, quality, and themes. Data sources PubMed, Web of Science, and EMBASE databases were systematically searched 2.1.2023. Study selection Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses rapid review. Citations discussing ethical guidance for, initiation/continuation/discontinuation decision-making, or allocation of, devices in children were identified. Devices included tracheostomy/mechanical ventilation (MV), renal replacement therapy (RRT), mechanical circulatory support (MCS), and extracorporeal membrane oxygenation (ECMO). We included policy statements/guidelines, reviews, conceptual articles, and surveys. Data extraction A standardized extraction tool was used. Quality was assessed using a multimodal tool. Data synthesis Of 97 citations, ethical analysis was the primary objective in 31%. 55% were pediatric-specific. Nineteen percent were high-quality. The USA and Europe were overrepresented with 12% from low- to middle-income countries. Devices included MV (40%), RRT (21%), MCS/ECMO (35%). Only one guideline was identified with a primary goal of ethical analysis of pediatric device use. Three empiric analyses examined patient-level data according to guideline implementation and 24 explored clinician/public perspectives on resource allocation or device utilization. Two non-empiric citations provided pediatric decision-making recommendations. Conclusions This comprehensive review of ethical guidance for device use in children identified numerous gaps and limited scope. Future research is warranted globally to promote the beneficial use of devices, minimize harm, and ensure equitable access.