Withdrawing extra corporeal membrane oxygenation (ECMO) against a family's wishes: Three permissible scenarios.

The ethical permissibility of unilaterally withdrawing life-sustaining technologies has been a perennial topic in transplant and critical care medicine, often focusing on CPR and mechanical ventilation. The permissibility of unilateral withdrawal of extracorporeal membrane oxygenation (ECMO) has been discussed sparingly. When addressed, authors have appealed to professional authority rather than substantive ethical analysis. In this Perspective, we argue that there are at least three (3) scenarios wherein healthcare teams would be justified in unilaterally withdrawing ECMO, despite the objections of the patient's legal representative. The ethical considerations that provide the groundwork for these scenarios are, primarily: equity, integrity, and the moral equivalence between withholding and withdrawing medical technologies. First, we place equity in the context of crisis standards of medicine. After this, we discuss professional integrity as it relates to the innovative usage of medical technologies. Finally, we discuss the ethical consensus known at the "equivalence thesis." Each of these considerations include a scenario and justification for unilateral withdrawal. We also provide three (3) recommendations that aim at preventing these challenges at their outset. Our conclusions and recommendations are not meant to be blunt arguments that ECMO teams wield whenever disagreement about the propriety of continued ECMO support arises. Instead, the onus will be on individual ECMO programs to evaluate these arguments and decide if they represent sensible, correct, and implementable starting points for clinical practice guidelines or policies.

Responding Well to Spiritual Worldviews: A Taxonomy for Clinical Ethicists.

Every clinical ethics consultant, no matter their own spirituality, will meet patients, families, and healthcare professionals whose spiritualities anchor their moral worldviews. How might ethicists respond to those who rely on spirituality when making medical decisions? And further, should ethicists incorporate their own spiritual commitments into their clinical analyses and recommendations? These questions prompt reflection on foundational issues in the philosophy of medicine, political and moral theory, and methods of proper clinical ethics consultation. Rather than attempting to offer definitive answers to these questions, this essay prompts readers to consider their own answers to these questions. Specifically, it offers a taxonomic analysis of six (6) distinct responses: assessment, delegation, examination, translation, incorporation, and assertion. Furthermore, this essay describes the role of the ethicist's own spiritual commitments during the responses. Each section also names several strengths and weaknesses that ethicists ought to consider when evaluating the purpose and scope of each response. This paper prompts readers to consider circumstances under which they might promote, critique, or incorporate spiritual worldviews-their own and those of their patients-when offering clinical analyses and recommendations.

Building Effective Mentoring Relationships During Clinical Ethics Fellowships: Pedagogy, Programs, and People.

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow's transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has created to assist our fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows.

COVID-19 vaccination status should not be used in triage tie-breaking.

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public's trust, which for the time being would not be served by the inclusion of vaccination status.

Caring for Unvaccinated Patients in the ICU: Beyond Frustration, Toward Beneficial Relationships.

Critical care professionals in the United States are experiencing distress and frustration during the recent delta-wave of the coronavirus disease 2019 pandemic. This wave feels different because most, although not all, patients suffering with the sequelae from coronavirus disease 2019 who enter ICUs are unvaccinated. Since vaccines in the United States are safe, effective, and widely available for people 12 and older, severe cases of coronavirus disease 2019 are now considered preventable. However, even when a disease is preventable, critical care professionals still have remaining role-based, ethical obligations to their patients. Developing additional mechanisms for reflection and resilience, in spite of accumulated frustrations from otherwise preventable mortality, may help the professional and those they care for. In this essay, we propose a number of questions that recognize the existential frustrations critical care professionals experience, while also uncovering the ethical obligations that remain. Rather than becoming comfortable with silence or frustration, these reflections intend to bridge the gap between feeling frustrated and building relationships that benefit both the patient and the critical care professional during this pandemic.

A Process-Based Approach to Responding to Parents or Guardians Who Hope for a Miracle.

When parents or guardians hope for a miracle for their child who is critically ill, ethical and professional challenges can arise. Often, although not always, the parent or guardian's hope for a miracle entails a request for continued life-sustaining interventions. Striking a balance between the pediatrician's conception of good medicine and the parent or guardian's authority requires a response that is sensitive, practical, and ethically sound. In this article, we recommend 3 cumulative steps that promote such a response. First, we recommend ways of exploring essential issues through open inquiry, interdisciplinary dialogue, and self-reflection. As part of this exploration, pediatricians will discover that parents or guardians often have unique ideas about what a miracle might be for their child. The second step includes analyzing this diversity and seeking understanding. We classify the hope for a miracle into 3 distinct categories: integrated, seeking, and adaptive. After the pediatrician has categorized the parent or guardian's hope, they can consider specific recommendations. We detail context-specific responses for each kind of hope. By attending to these nuances, not only will the parent or guardian's perspective be heard but also the pediatrician's recommendation can strike a balance between advocating for their conception of good medicine and respecting the parent or guardian's beliefs.

"Do we have to replace the balloon pump when it fails?"

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra-aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and deconditioned. The attending deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, "Do we have to replace the balloon pump when it fails?"

"What if she was your mother?" Toward better responses.

Critical care physicians may hear a surrogate decision-maker ask, "What would you do if she was your mother?" or "What if your father was this sick?" These kinds of questions ask more of the critical care physician than the surrogate might realize. There are deep-seated ethical, professional, and personal complexities that can challenge critical care physicians to answer these questions with honesty. This essay offers practical guidance for critical care physicians who aim to respond to such queries with honesty and beneficence. We discuss a variety of motivations that can accompany this unique kind of question from a surrogate. The surrogate may be seeking moral guidance-the true question being, "What should I do?" We offer a number of questions that the critical care physician might ask of the surrogate in order to attend to both the surrogate's moral dilemma and the patient's values and preferences for medical interventions. We also offer a number of questions to promote contemplation of these issues by the critical care physician herself. We argue that until the critical care physician: discovers the surrogate's motivation, connects this motivation to patient preferences, and asks herself important questions regarding death and dying, the physician's responses will not adequately attend to the issues prompted by such questions.

Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists.

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, "How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?" We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle.

Addressing a Patient's Hope for a Miracle.

Ill patients may make decisions to continue aggressive life-prolonging care based on hope for a miraculous recovery, and clinicians can find goals of care discussions with these patients extremely challenging. Thus, palliative care providers may be asked to help in these discussions. The concept of "miracle" can express a multitude of hopes, fears, and religious commitments. Effective, sensitive engagement requires the palliative care provider to attend to these variegated hopes, fears, and commitments. This case presents a typology of ways patients express hope for a miracle along with analysis of the motivations and beliefs underlying such hopes and suggestions for tailored responses by palliative care providers.

Ethics and Brain Death in Pediatrics: Recent Controversy and Practical Suggestions.

Who decides when a child is dead? The story of Jahi McMath has brought this question into focus for pediatric intensivists, ethicists, and the American public. In this article, we address this question by arguing that medical professionals do not have an obligation to acquiesce when families insist upon postmortem therapies. To do so may harm the dignity of the child by subjecting him or her to procedures that objectify the body, damage the child's reputation, and violate his or her privacy. Applying this answer to the real world of pediatric intensive care, we suggest practices meant to preserve the dignity of the child while accepting that the family is struggling to understand the tragedy. Muddled communication or an unyielding attitude will fail to help the family understand and cope with the death of their young loved one. Clear and honest communication-in conjunction with an empathetic disposition-can improve pre- and postmortem care for both patient and family.

A Qualitative Exploration of a Clinical Ethicist's Role and Contributions During Family Meetings.

Despite the interpersonal nature of family meetings and the frequency in which they occur, the clinical ethics literature is devoid of any rich descriptions of what clinical ethicists should actually be doing during family meetings. Here, we propose a framework for describing and understanding "transitioning" facilitation skills based on a retrospective review of our internal documentation of 100 consecutive cases (June 01, 2013-December 31, 2014) wherein a clinical ethicist facilitated at least one family meeting. The internal documents were analyzed using qualitative methodologies, i.e., "codes", to identify emergent themes. We identified four different transitioning strategies clinical ethicists use to reach a meaningful resolution. These transitioning strategies serve as a jumping-off point for additional analyses, future research, evaluating clinical ethics consultation, and overall performance improvement of a consultation service.