Author: Jordan Francke, MD, MPH
IARS 2026 Annual Meeting coverage
Advances in extracorporeal membrane oxygenation and organ transplantation have created difficult ethical questions for intensivists, patients, and families. During the 2026 IARS and SOCCA Annual Meeting, a panel examined when invasive support should be initiated, when it should be withdrawn, and whether newer organ-procurement techniques are consistent with established definitions of death.
Shahla Siddiqui, MBBS, MSc, described how critical care decisions are frequently made under intense time pressure and with uncertain prognoses. When a patient’s wishes are unclear, clinicians may feel compelled to begin aggressive treatment unless death is clearly irreversible or the risks plainly outweigh the potential benefits.
ECMO may initially be used as a bridge to heart or lung transplantation. However, some patients later become ineligible for transplantation. At that point, the temporary bridge becomes the final destination—a situation Dr. Siddiqui described as a “bridge to nowhere.”
This creates substantial moral distress. Clinicians and families must decide whether continued support still benefits the patient or merely prolongs dying without a realistic path to recovery or transplantation.
Jai Madhok, MD, MSE, discussed the challenge of determining which patients should receive ECMO. Decisions may vary according to institutional experience, available equipment, referral speed, the patient’s disease, comorbidities, and perceived likelihood of becoming a transplant candidate.
Risk-assessment tools such as the PRESERVE score may help estimate six-month survival in patients receiving ECMO for severe acute respiratory distress syndrome. However, clinical judgment remains vulnerable to cognitive biases.
Common biases include:
- Recency bias, in which a clinician recalls a recent unexpected recovery
- Sunk-cost bias, in which prior investment makes withdrawal of treatment more difficult
- Optimism based on isolated exceptional outcomes
- Institutional differences in resources and experience
Dr. Madhok also raised a more complex question: What should happen when a patient is no longer eligible for transplantation but remains awake, interacts with family, and continues to find meaning in life?
Although ECMO is no longer serving as a bridge to definitive treatment, it may still be supporting a life the patient considers valuable. This challenges the assumption that treatment is inappropriate merely because it cannot lead to transplantation or long-term recovery.
Louanne Carabini, MD, MA, FASA, addressed ethical concerns surrounding donation after circulatory death and thoracoabdominal normothermic regional perfusion.
During this procedure, circulation is restored to abdominal and thoracic organs after the vessels supplying the brain are surgically blocked. The goal is to preserve organ function while preventing blood flow from returning to the brain.
However, collateral arterial circulation to the brain cannot always be completely excluded. This raises questions about whether restored circulation conflicts with the legal definition of death based on the irreversible cessation of circulatory and respiratory function.
The technique has also generated debate about the Dead Donor Rule. Dr. Carabini explained that this rule does not mean organ procurement can occur only after every biological function has permanently stopped. Rather, the procurement process itself must not cause the donor’s death.
Key Takeaways
ECMO should not be initiated without considering what will happen if transplantation or recovery later becomes impossible. Whenever feasible, clinicians should establish treatment goals, stopping criteria, and the patient’s preferences before invasive support begins.
Decisions should consider more than survival statistics. A patient’s current awareness, comfort, relationships, values, and experience of meaningful life may also influence whether continued treatment remains appropriate.
New organ-recovery techniques such as thoracoabdominal normothermic regional perfusion require clear ethical standards, transparent explanations, and careful attention to accepted definitions of death.
Hospitals should educate clinicians and families about these procedures and allow health care professionals to decline participation when involvement would create serious ethical conflict or moral injury.
Public trust is essential to organ transplantation. Poorly explained procedures or uncertainty about whether death is truly irreversible could discourage people from remaining registered organ donors.
Thank you to IARS for allowing us to summarize this important coverage from the 2026 Annual Meeting.