Critical Care
Critical Care 2
Maneesha Limaye, MD/MPH
Fellow
Lucile Packard Children's Hospital Stanford
Redwood City, California, United States
Extracorporeal cardiopulmonary resuscitation (ECPR) is a high-risk and complex, lifesaving intervention with increased use worldwide. However, controversy remains regarding circumstances of initiation and overall benefit. Disagreement between providers may be related to differing attitudes and goals that ultimately may affect clinical team performance. To better explore provider viewpoints, we conducted the first qualitative study of the ECPR experience of three groups of caregivers: surgeons, intensivists, and perfusionists.
Objective:
The aim of this study was to explore the perceptions and experiences of physicians and perfusionists who perform ECPR.
Design/Methods:
Participants were asked to complete a survey to collect demographic and ECPR experience. Individual, semi-structured interviews were then conducted to solicit perspectives regarding ECPR. Interviews were audio recorded, transcribed (Rev, San Francisco, CA) and imported into Dedoose (Los Angeles, CA) for coding. Analysis followed grounded theory principles using an iterative process. Inter-rater reliability testing between two coders resulted in kappa ≥ 0.7 (pooled score of 0.85) for all codes.
Results:
A total of 15 participants (5 surgeons, 5 intensivists, 5 perfusionists) were included. Survey response rate was 73% (11/15) with 36% (4/11) reporting experience of more than 15 ECPR cases. All participants completed interviews. Four major themes were identified: the value of ECPR, decision-making for candidacy, barriers to care, and capacity for improvement. There was discordance in the value of ECPR between intensivists/perfusionists and surgeons. Intensivists/perfusionists believed ECPR fulfilled a “duty to try” and provided time for families. Surgeons believed ECPR survival outcomes precluded offering surgical intervention and prolonged patient/family suffering. All groups had differing perspectives regarding decision-making for candidacy. Intensivists reported responsibility to activate ECPR but endorsed shared decision-making with surgeons. Surgeons felt “at the mercy” of the intensivists and noted difficulty in challenging the decision. All perfusionists deferred to medical providers. There was concordance of themes regarding barriers to care and capacity for improvement across groups.
Conclusion(s):
Discordance in the value of ECPR and decision-making for candidacy is reflective of provider attitudes and goals, but the impact on clinical team performance is unclear. Further research is warranted to determine whether misalignment between providers influences care delivery and should be an important area of focus for ECPR programs.