A Qualitative Approach to Pediatric ECMO Candidacy Decisions

Introduction: Patients with pediatric chronic critical illness (PCCI) utilize substantial intensive care resources, including extracorporeal membrane oxygenation (ECMO). Few absolute contraindications to ECMO exist, and in the absence of concrete guidelines, variation in patient candidacy decisions may arise for patients with PCCI. Using principles from the critical decision method (CDM), a technique utilized to understand expert decision-making in non-routine cases, we interviewed pediatric intensivists regarding ECMO candidacy for patients with PCCI.


Methods: We conducted 16 semi-structured interviews with pediatric intensive care physicians at Children’s Medical Center in Dallas, TX using an original interview guide grounded in CDM. Interviews were conducted and transcribed by the primary investigator. Transcripts were coded for thematic analysis informed by grounded theory. Three investigators utilized a predominantly inductive approach based on this framework to create a coding protocol, from which transcripts were coded and themes derived. Completion of thematic analysis anticipated in Fall 2025.


Results: Participating intensivists had varying levels of experience, with the number of years post-critical care fellowship ranging from less than five (31%) to more than 15 (25%). Participants included faculty with cardiac intensive care experience (31%) and ECMO leadership and education experience (43%).

With prompting to recall cases using CDM techniques, participants discussed complexities of ECMO candidacy determinations for PCCI patients. Interview themes included importance of case discussion with colleagues and the need to gather information on a patient’s neurological “baseline” or functional status as part of candidacy determination for PCCI patients, with high value placed on perceived patient interaction with caregivers. Participants also reflected on intensivist leadership to help team members navigate moral distress that may arise while caring for children during prolonged ECMO runs.


Conclusions: Pediatric ECMO candidacy decisions for PCCI patients are complex and variable. Emerging themes from interviews based in CDM with pediatric intensivists regarding candidacy for PCCI patients provide insights into the decision-making process that can inform future research.