Turning down young patients for ECMO support can be especially hard, but is sometimes the right decision when they are at the end stage of a chronic disease with little or no treatment options. As the ECMO physician, it is not your job to determine the prognosis of their underlying condition, but only to sufficiently understand it to make an informed decision on the appropriateness of ECMO. Patients who present with an initial or early episode of lupus, for example, with hypoxemia from acute pneumonitis are excellent candidates for support since they have a number of treatment options likely to be successful in resolving the inflammation (e.g. plasmapheresis, steroids, other anti-inflammatory drugs, etc.). However, patients with numerous admissions for significant exacerbations of their disease who are already on one or more treatment regiments at home, and who may have exhausted new therapeutic options, may be approaching the “end-stage” of their disease process, and are unlikely to be helped by ECMO support. Consultation with the rheumatologist (or oncologist, pulmonologist, endocrinologist, etc. as appropriate) is not only helpful, but essential in making a decision about ECMO support in patients with chronic illnesses.

Angela is a tragic example of a very early presentation of an auto-immune disease that has clearly taken its toll on her. She has had gradual worsening of her lung disease, and after consultation with her rheumatologist, he had very little new options to offer (she had previously been treated with Cytoxan with minimal improvement). Prior to declining her for support, a consultation for lung transplant was obtained, mostly for completeness, and as expected, she was not a candidate. The primary team discussed the poor prognosis with the parents and a DNR order was requested, and comfort care continued. She expired 10 days later.