Decision-making and institutional support for ECMO and ventilator allocation during the COVID-19 pandemic: a nationwide cross-sectional survey of designated physicians at Japan’s advanced critical care and emergency centers

During the COVID-19 pandemic, physicians in Advanced Critical Care and Emergency Centers (ACCECs) were required to make ethically and emotionally challenging decisions regarding the allocation of extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV). Although expert-group guidance existed, no legally binding triage criteria were established in Japan. How these physicians balanced clinical indicators with ethical considerations—and whether institutional support systems helped or hindered these decisions—remains insufficiently understood. We conducted a nationwide, cross-sectional retrospective survey of all 50 ACCECs in Japan (February–March 2025). Respondents recalled ECMO/MV allocation decisions made during the COVID-19 pandemic (2020–2023). One physician per center, who had been directly involved in ECMO/MV decision-making during the pandemic, completed a 16-item questionnaire addressing (1) treatment restriction or withdrawal, (2) clinical and non-clinical criteria used, (3) ethical values prioritized, (4) psychological burden, and (5) institutional ethics support. Descriptive analyses were performed. Twenty-seven centers responded (54.0%). Among 26 centers with prior ECMO capability, 10 (38.5%) restricted ECMO indications, most frequently based on patient age (80.0%), survival likelihood (60.0%), and illness severity (50.0%). Non-clinical criteria—including social background and first-come, first-served approaches—were used infrequently but still present. Early withdrawal of ECMO or MV occurred in 18.5% and 14.8% of centers, respectively. Efficiency was the most frequently prioritized ethical value (56.5%), followed by equality and autonomy (each 21.7%). Nearly half of respondents (48.1%) reported an elevated psychological burden. Centers with institution-specific guidelines (“internal rules”) more often implemented treatment restrictions (70.0% vs. 17.6%). Ethics consultations were used by 18.5% of respondents. In the absence of standardized triage criteria, physicians made complex allocation decisions using a combination of clinical judgment and ethical considerations. Although efficiency was the most frequently selected ethical priority, equality and autonomy also informed decision-making. Internal rules appeared to legitimize difficult decisions but were not associated with reduced psychological burden. These findings suggest that practical, context-sensitive forms of ethics support may better assist clinicians in navigating resource scarcity during future public health emergencies.