Moral failure in critical care: reflections on how we teach ethics

Toby, a middle-aged man, was admitted to the intensive care unit with cardiogenic shock. Because his condition deteriorated rapidly, he was sedated, intubated, ventilated, and placed on venoarterial (VA) extracorporeal membrane oxygenation (ECMO). After 40 days, he remains dependent on VA-ECMO, has necrotizing pneumonia, and is not a suitable candidate for a left-ventricular assist device or transplant. The health care team is uncertain how best to proceed with his care. They are considering a pneumonectomy (ie, complete removal) of the necrotic lung, but this surgery is not possible until the patient is stable off VA-ECMO. The health care team thinks they have optimized the heart and that VA-ECMO decannulation is now indicated. However, they are worried that removing Toby from VA-ECMO could lead to his death and consider placing him on venovenous (VV) ECMO in the interim to support his lungs, but whether this treatment would be beneficial is unclear. The health care team is concerned that rather than increasing his chances of survival, such a procedure might prolong his suffering before death. Toby’s wife, Jenna, has been involved in Toby’s care and stated that if Toby’s condition deteriorates she wants the health care team to continue life-sustaining treatments, whether that is VA-ECMO or VV-ECMO. The dilemma regarding which treatment option to take is causing anxiety among the health care team. The team wants to give Toby every chance of survival, but does not want to cause unnecessary suffering and prolong the dying process. The bedside nurses feel distressed because they have struggled to achieve optimal levels of sedation and analgesia for Toby and are sure that he has experienced pain during routine nursing care and is suffering as a result.