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Allocating scarce cardiovascular support in a pandemic: ECMO in crisis standards of care
  1. Danish Zaidi1,
  2. Savitri E Fedson2,3,
  3. James N Kirkpatrick4
  1. 1 Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  2. 2 Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
  3. 3 Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
  4. 4 Department of Medicine/Division of Cardiology, Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
  1. Correspondence to Dr James N Kirkpatrick, University of Washington, Seattle, WA 98195-0005, USA; kirkpatj{at}

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The COVID-19 pandemic underscored a need for robust ethical frameworks in approaching challenges and biases associated with allocating scarce resources. This is particularly relevant in relation to cardiopulmonary support devices, employed to sustain life in the setting of acute and otherwise life-ending cardiopulmonary decompensation. Extracorporeal membrane oxygenation (ECMO) exemplifies scarce, expensive resources that require thoughtful consideration relating to ethical and clinical implications of rationing care in exigent circumstances.

Defining crisis standards

A 2014 CHEST consensus statement on pandemic and disaster response portrayed standards of care along a spectrum: conventional, contingent and crisis.1 The characteristics distinguishing these standards include the magnitude of patient surge, response strategies (eg, conserving vs reusing) and the extent of departure from known standards of care.

Whereas conventional standards of care are ‘business as usual’, contingent standards anticipate shortages by conserving resources without compromising usual care quality. In crisis, however, usual standards cannot be met for all patients due to limited resources, and difficult decisions must be made about which patients will receive scarce resources. In instances like Hurricane Katrina or the COVID-19 pandemic, many hospitals met criteria for crisis standards, with critical patient volumes and a departure fromtraditional standards of care secondary to resource shortages.

Reallocation and rationing are two strategies unique to exigent circumstances. Despite notable crisis scenarios, there is reticence to adopt strategies that deny interventions to some patients while providing for others, as doing so undermines the traditional view of autonomy as primus inter pares among principles in clinical ethics. Transitioning from contingency to crisis standards …

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  • Contributors All authors provided significant contributions to the ideas, drafting and completion of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; internally peer reviewed.