Bridge to Decision, Bridge to Nowhere: Ethical and Clinical Challenges in Temporary Mechanical Circulatory Support

The use of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and other forms of temporary mechanical circulatory support (tMCS) has grown significantly in contemporary practice. With this surge, there has been a corresponding increase in "bridge to decision" ECMO and tMCS cases in which the pathway towards long-term survival is not delineated at the time the patient is placed on these forms of support. However, prolonged tMCS may be associated with a lower likelihood of successful weaning and an increased risk of complications. Healthcare teams should continuously evaluate patients for all potential exit strategies off tMCS, including native cardiopulmonary recovery, heart transplantation, durable left ventricular assist device, and palliative discontinuation. Early and frequent open communication among the healthcare team, patients, and families should include preparedness planning—to anticipate and navigate potential complications—and education on potential clinical trajectories and realistic outcomes. Additionally, developing and executing time-limited trials may promote shared decision-making and provide the necessary structure and guidance to help manage patients with unclear clinical conditions. These challenges raise significant ethical questions surrounding consent, autonomy, proportionality, and the responsibility of the care team to prevent prolonged nonbeneficial treatment.