Disclosure(s): No relevant financial relationship(s) to disclose.
First Author: Derek R. Soled, MD, MBA, Mac – Brigham and Women's Hospital Co-Author: Jacqueline Kruser, MD, MS – Assistant Professor, University of Wisconsin School of Medicine and Public Health Co-Author: Alexander Jacobs, MD – Resident Physician, Massachusetts General Hospital Co-Author: Rebecca M. Baron, MD – Associate Professor, Brigham and Women's Hospital Co-Author: Eddy Fan, MD, PhD – Associate Professor, University Health Network Co-Author: James C. Henderson, ScM – Medical Student, Johns Hopkins University School of Medicine
Introduction: Extracorporeal membrane oxygenation (ECMO) is a resource-intensive, life-sustaining technology that supports patients whose heart and/or lungs are failing. Indications and contraindications for ECMO are not standardized, frequently changing, and sometimes contradictory, leading to variation in who and why patients receive or fail to receive ECMO. This study sought to understand the various ways that ECMO centers approach candidacy selection and how different variables are considered in the decision-making process.
Methods: This qualitative study involved semi-structured interviews of individuals involved in selecting ECMO candidates. A purposeful sample of 45 individuals from different centers were contacted, and 24 (53%) enrolled. One investigator conducted all interviews between September and December 2024, with each interview lasting approximately one hour. From January to June 2025, interview transcripts were analyzed using inductive and deductive thematic analysis. A coding dictionary was created and continuously refined. Two investigators performed line-by-line consensus coding and generated meaningful themes, subthemes, and higher-level conceptual links.
Results: Among the 24 participants interviewed, 21 (88%) were physicians and 3 (12%) were ECMO coordinators; 5 (21%) were female, 8 (33%) practiced outside of the U.S., and 9 (38%) identified as a race or ethnicity other than White. Four main themes were identified: (1) clinicians vary in how they interpret and incorporate patient age, body mass index (BMI), and time on mechanical ventilation in selecting ECMO candidates; (2) cognitive biases and heuristics influence the ECMO decision-making process; (3) relative contraindications to ECMO are often flexible depending on various ethical and social criteria; and (4) institutional and cultural contexts shape individual ECMO candidacy decisions.
Conclusions: Decisions about whether to pursue ECMO for patients with severe heart and/or lung failure are largely based on clinical judgements of suitability rather than objective guidelines. Determining a patient’s candidacy may be based on different and flexible interpretations of patient characteristics (e.g., age, BMI, and time on the ventilator), biases, and social contexts. Such variability means ECMO may not currently be equitably allocated.
