Ethical and governance challenges in extracorporeal membrane oxygenation: a scoping review and practical framework for clinical and system-level decision-making

Abstract Background Extracorporeal membrane oxygenation (ECMO) is an advanced life-sustaining therapy used in selected patients with severe cardiac or respiratory failure. Its increasing use has raised complex ethical, clinical, organizational, and medico-legal challenges related to patient selection, allocation, continuation, and withdrawal of support. Aim This scoping review aimed to map the literature on ethical and governance challenges in ECMO, identify key areas of consensus, controversy, and evidence gaps, and propose a practical framework for clinical and system-level decision-making. Methods A scoping review was conducted in accordance with Joanna Briggs Institute methodology and reported according to PRISMA-ScR. PubMed/MEDLINE and Scopus were searched for literature addressing ethical, decision-making, governance, and medico-legal aspects of ECMO, with a supplementary Cochrane Library search. Full search strategies and filters are reported in the supplementary material. Findings were organized using a narrative and framework synthesis approach. Results The included literature was mapped into eight recurrent domains, which were refined iteratively during data charting and framework synthesis: ECMO candidacy and patient selection; prognostic uncertainty and cognitive bias; resource allocation and triage; family and surrogate decision-making; withholding, withdrawal, futility, and time-limited trials; palliative care integration; moral distress and professional burden; and medico-legal implications and institutional governance. These domains informed an eight-step practical framework linking referral and eligibility assessment, prognostic and proportionality assessment, multidisciplinary deliberation, family communication, time-limited trials, scheduled reassessment, decisions on continuation, weaning, transition or withdrawal, and institutional or regional review. Across these domains, ECMO decision-making was characterized by variability in candidacy criteria, reliance on clinician judgment, uncertainty regarding prognosis and proportionality, inconsistent integration of palliative care and ethics consultation, and substantial ethical tension around withdrawal and resource allocation. Prognostic scores and guidelines may support decision-making but cannot replace multidisciplinary deliberation, transparent governance, and explicit attention to patient values and system-level fairness. Conclusions The findings support an integrated governance approach that combines clinical expertise, prognostic assessment, ethical principles, structured family communication, palliative care, ethics consultation, and institutional accountability. The proposed framework may support more transparent, consistent, equitable, and goal-concordant ECMO decisions across the trajectory from referral to recovery, transition, or withdrawal of support.