# Clinician Perspectives on the Extracorporeal Membrane Oxygenation Decision-Making Process

## TL;DR

This study examines how clinicians decide who gets a life-saving ECMO treatment, finding that decisions rely more on personal judgment than clear guidelines.

## Contribution

The study reveals how subjective factors and biases influence ECMO candidacy decisions, highlighting the lack of standardized criteria.

## Key findings

- Clinicians use flexible interpretations of patient characteristics rather than objective guidelines for ECMO selection.
- Cognitive biases and institutional contexts significantly affect ECMO candidacy decisions.
- Participants suggested ways to improve consistency in ECMO allocation.

## Abstract

This qualitative study explores the specific variables considered in selecting patients for venovenous extracorporeal membrane oxygenation (ECMO).

In patients for whom venovenous extracorporeal membrane oxygenation (VV ECMO) may be medically indicated, how do clinicians approach candidacy determinations and consider different variables in the decision-making process?

In this qualitative study of 24 physicians and ECMO coordinators from 9 countries, decisions to pursue VV ECMO for patients were largely based on clinical judgments of suitability rather than objective guidelines. Determining patient candidacy may be based on flexible interpretations of patient characteristics, biases, and social contexts.

The findings showed that, as ECMO is better understood and adopted in critical care medicine, ethical questions remain about how VV ECMO candidacy is variably determined.

Venovenous extracorporeal membrane oxygenation (VV ECMO) is a resource-intensive, life-sustaining technology to support patients with severe refractory respiratory failure. Its precise indications and contraindications are not standardized, and expert opinions are frequently changing, leading to variation in why and to whom VV ECMO is offered.

To characterize the ways clinicians approach candidacy selection, the criteria considered, and the relative weight given to such variables.

This qualitative study conducted virtual semistructured interviews of clinicians between September and December 2024. Transcripts were qualitatively analyzed from January to June 2025 using both inductive and deductive approaches to thematic analysis and line-by-line consensus coding. Participants were physicians and ECMO coordinators from various urban, rural, public, and private medical centers in 9 countries.

Themes and subthemes that reflected clinicians’ experiences and views.

A purposeful sample of 45 clinicians directly involved in ECMO candidacy selection were contacted, of whom 24 (19 males [79%]) enrolled. Among these 24 participants interviewed, 21 (88%) were physicians and 3 (12%) were ECMO center coordinators; 8 (33%) practiced outside of the US. Five main themes were identified: (1) clinicians vary in their interpretation and incorporation of patient age, body mass index, and time on mechanical ventilation when selecting VV ECMO candidates; (2) perceived contraindications to VV ECMO are often flexible depending on various ethical and social criteria; (3) cognitive biases and heuristics affect the VV ECMO decision-making process; (4) institutional and cultural contexts shape individual VV ECMO candidacy decisions; and (5) participants provided suggestions to improve consistency in VV ECMO candidacy selection.

In this qualitative study, decisions to pursue VV ECMO for patients with severe respiratory failure were largely based on clinical judgments of suitability rather than objective guidelines. Variability in candidacy decision-making may lead to inconsistent or inequitable allocation.