Proposed section structure
This topic is best organized into a clinically oriented framework that moves from context to methods, then to practice-changing implications. A logical structure is: Highlights; Clinical context and why ECLS end-of-life decisions are uniquely difficult; Study design and survey methods; Key results, including who participates in decisions, how treatment is limited or withdrawn, and regional variation; Interpretation and clinical implications; Limitations and unanswered questions; Practical next steps for ICUs and ECLS programs; Conclusion; Funding and citation.
Highlights
First, the ENSURE survey identifies marked variation across Europe in reported end-of-life practices for patients receiving extracorporeal life support, suggesting that discontinuation decisions are shaped not only by clinical prognosis but also by culture, region, religion, and institutional context.
Second, when ECLS treatment goals are no longer achievable, 41% of respondents reported stopping ECLS and transitioning to comfort care, but this approach was much more commonly reported in Northern and Western Europe than in Southern and Eastern Europe, where limitation of other life-sustaining treatments without stopping ECLS was more frequently described.
Third, multidisciplinary involvement is common but uneven: physicians, nurses, and relatives are often included in discussions, yet access to formal ethics support remains incomplete, and nearly one-quarter of respondents reported no ethics support for difficult decisions.
Fourth, the survey underscores a major systems issue rather than only an individual moral problem: many ECLS programs appear to lack standardized protocols, embedded palliative care, or accessible clinical ethics services, all of which may contribute to inconsistency and moral distress.
Clinical context: why end-of-life decision-making during ECLS is uniquely challenging
Extracorporeal life support, including venoarterial and venovenous extracorporeal membrane oxygenation, is one of the most intensive rescue therapies used in critical care. It can temporarily support gas exchange and/or circulation in patients with otherwise refractory cardiac or respiratory failure. In selected patients, ECLS is life-saving. But when recovery, transplantation, durable mechanical support, or other meaningful treatment goals are no longer attainable, clinicians and families face some of the most difficult decisions in ICU practice.
Unlike many other life-sustaining treatments, ECLS has a powerful symbolic and emotional weight. It is technologically complex, highly visible, labor-intensive, and often initiated in moments of crisis. Withdrawal can feel different from withholding treatment, even though many ethical frameworks regard them as morally equivalent when treatment no longer meets patient-centered goals. The continuous and invasive nature of ECLS may also intensify staff distress, particularly when clinicians perceive ongoing support as nonbeneficial or potentially prolonging dying.
These challenges are not purely theoretical. The literature on ECMO and moral distress has consistently shown tensions around prognostic uncertainty, team disagreement, family expectations, and the timing of transition to palliative goals. International ELSO guidance has increasingly emphasized the importance of advance discussions about candidacy, goals of therapy, triggers for reevaluation, and communication around futility or nonbeneficial treatment. Yet real-world practice remains heterogeneous, especially across countries with different legal, cultural, and religious norms.
The ENSURE survey therefore addresses an important gap: how ECLS end-of-life decision-making is actually reported across Europe, and what institutional supports are available when these decisions become ethically fraught.
Study design and methods
ENSURE, short for ENd-of-life deciSion-making dURing Extracorporeal life support, was an international survey conducted within the European chapter of the Extracorporeal Life Support Organization. The survey contained 20 online questions divided into two main domains. The first collected information on hospital characteristics, ICU profile, ECLS provision, and the respondent’s professional role. The second focused on clinical practice, institutional protocols, management strategies, and palliative care arrangements related to discontinuation of ECLS.
The survey was translated into 31 native European languages, an important methodological choice that likely improved accessibility and geographic reach. It sought to capture reported actual practice rather than hypothetical preferences alone. Responses were obtained from 570 participants across 28 European countries.
The abstract indicates that the survey population included clinicians involved in the care of critically ill patients on ECLS when treatment goals are no longer achievable. No intervention or comparator group was involved, as this was a descriptive cross-sectional survey. The principal outcomes were patterns of participation in decision-making, institutional ethics and palliative care resources, and reported approaches to ECLS discontinuation or limitation of life-sustaining treatment.
As with all survey studies, the findings should be interpreted as reported practice rather than audited bedside behavior. Still, the large multinational sample makes the dataset highly informative for mapping current European practice patterns.
Key findings
Who is involved in end-of-life discussions?
Decision-making around ECLS appears to be predominantly physician-led, but not physician-only. Physicians were reported as being involved in end-of-life discussions by 99% of respondents, which is expected given the legal and clinical responsibility attached to treatment limitation decisions in most ICUs. Nurses were involved in 63% of cases, and relatives in 54%.
This distribution matters. Nursing involvement at 63% suggests that bedside professionals who often observe patient trajectory most closely are frequently, but not universally, included. That leaves a substantial minority of settings where nurses may not be consistently integrated into formal discussions despite their central role in symptom assessment, communication, continuity, and family support. The reported 54% involvement of relatives likewise indicates that family participation is common but not assured. In ECLS, where many patients lack decisional capacity and advance directives may be absent, family communication becomes critical not only for substituted judgment but also for trust and conflict prevention.
What ethics support is available?
One of the most clinically actionable findings concerns ethics infrastructure. Forty-nine percent of institutions reportedly offered access to a clinical ethics committee, and 12% provided access to clinical ethicists. However, 24% lacked any ethics support for challenging decisions.
This is a striking systems-level deficiency. ECLS decisions often involve disagreements about prognosis, proportionality, acceptable burden, and whether ongoing therapy remains aligned with patient values. In such cases, ethics consultation can help clarify principles, improve process fairness, and reduce interpersonal conflict. The absence of any ethics support in nearly one-quarter of settings suggests that many teams are navigating extraordinarily difficult decisions without structured institutional assistance.
The numbers also imply that formal ethics input is still not embedded as routine care in most ECLS programs. Access to a committee is not the same as timely consultation, and access to an individual clinical ethicist remains uncommon. In high-stakes, time-sensitive ICU contexts, delayed or purely administrative ethics processes may be of limited practical value.
How do clinicians respond when ECLS goals fail?
When treatment goals were no longer achievable, 41% of respondents reported discontinuing ECLS and instituting comfort care. This approach is ethically consistent with many critical care frameworks that support withdrawal of nonbeneficial life-sustaining treatment when it no longer serves agreed clinical or patient-centered goals.
However, this was far from universal practice. Regional differences were substantial. Respondents from Northern and Western Europe were most likely to report discontinuing ECLS with comfort care, at 54% and 59%, respectively. By contrast, respondents from Southern and Eastern Europe more often reported limiting life-sustaining treatments without stopping ECLS, at 42% and 46%, respectively.
This distinction is clinically and ethically important. Limiting other treatments while continuing ECLS may represent an attempt to avoid the emotional and symbolic burden of active circuit withdrawal, or it may reflect legal uncertainty, professional norms, religious values, or family expectations. It can also reflect differing conceptions of what constitutes treatment withdrawal versus allowing natural death. Yet from a practical standpoint, continuing ECLS while withholding escalation may prolong the dying process, increase resource use, and intensify distress for staff and relatives if the care plan lacks clear goals.
The survey also found differences according to professionals’ religious backgrounds. The abstract does not provide detailed subgroup numbers, but the signal is important: clinicians’ personal moral frameworks may influence how acceptable they perceive ECLS discontinuation to be. This does not imply bias in a simplistic sense; rather, it highlights that end-of-life care in technologically dependent critical illness is deeply shaped by values as well as evidence.
What do these regional patterns likely reflect?
The observed variation almost certainly reflects more than bedside preference. Legal frameworks differ across European countries regarding treatment withdrawal, surrogate decision-making, and professional accountability. Institutional culture also matters. Some programs may normalize early goals-of-care discussions and ECLS as a time-limited trial, while others may treat discontinuation as exceptional or morally weightier than non-initiation.
Cultural and religious influences are also plausible. In some settings, withdrawal of a life-sustaining device may be perceived as more active or morally concerning than not adding additional therapies. In others, maintaining ECLS without realistic prospects of recovery may be viewed as medically inappropriate and burdensome. The survey cannot fully disentangle these influences, but it clearly shows that a supposedly high-technology, protocol-driven therapy remains embedded in local ethical worlds.
Interpretation and clinical implications
The principal contribution of ENSURE is that it reframes ECLS end-of-life decision-making as a problem of system design as much as moral philosophy. Variation in practice is not surprising. What is concerning is the scale of that variation and the incomplete availability of supports that might help teams navigate it consistently.
For clinicians, the results reinforce the need to define the goals of ECLS at the time of initiation. ECLS should ideally be framed as a bridge: to recovery, to transplantation, to durable support, or to diagnostic clarification over a limited period. When no bridge remains, teams need explicit processes for reassessment. This is particularly important because the momentum of ongoing ECLS can make continuation feel easier than withdrawal, even when prospects have clearly deteriorated.
For nurses and bedside staff, the survey validates a familiar reality: moral distress often emerges when the care being delivered appears misaligned with achievable goals, but clinicians feel unable to change direction. Greater nursing inclusion in formal deliberation, along with access to palliative care and ethics support, may help convert distress into structured dialogue and shared decision-making.
For institutions, the message is operational. ECLS centers should not rely solely on technical excellence. They also need robust governance around candidacy, reevaluation, communication, and end-of-life transitions. A mature ECLS program should be able to say not only how it cannulates and anticoagulates, but also how it handles nonrecovery, family meetings, symptom control after withdrawal, and team conflict.
How these findings align with existing literature and guidance
Existing guidance from the Extracorporeal Life Support Organization and broader critical care ethics literature supports several principles that fit the ENSURE findings. These include shared decision-making where possible, early and repeated communication about prognosis, recognition of ECLS as a time-limited trial, and integration of palliative care when goals shift away from recovery.
Prior work in ECMO populations has documented high mortality in certain refractory conditions despite technical support, substantial burdens on families, and significant moral distress among nurses and physicians. Reviews of ethics in ECMO have repeatedly highlighted challenges related to patient selection, perceived futility, withdrawal of support, and distributive justice, especially when resources are constrained. The ENSURE survey adds contemporary European practice data to that conceptual literature and shows that unresolved ethical questions continue to produce divergent bedside patterns.
Notably, the survey’s findings about limited ethics support mirror broader ICU literature showing that ethics consultation is inconsistently available, variably used, and often activated late. Palliative care involvement has similarly been shown to improve communication and symptom-focused care in critical illness, yet remains underused in many technologically intensive settings where teams may equate palliation with treatment failure rather than as a parallel layer of care.
Limitations
Several limitations should shape interpretation. First, survey data reflect self-report, which may differ from actual bedside practice. Respondents may describe institutional ideals, personal beliefs, or memorable cases rather than routine behavior.
Second, the abstract does not specify response rates by country, specialty, or center type. Without that information, representativeness is uncertain. Some countries or professional groups may be overrepresented, and high-volume ECLS centers may differ from lower-volume institutions in important ways.
Third, multiple respondents may have come from the same institution, potentially clustering certain practices. Fourth, the survey captures broad categories such as stopping ECLS with comfort care or limiting other treatments without stopping ECLS, but does not provide the granular clinical contexts that often drive decision-making, such as neurologic devastation, multi-organ failure, bridge failure, transplant ineligibility, or family conflict.
Finally, regional differences are descriptive and should not be overinterpreted as evidence that one region is uniformly better or worse. Variation may sometimes reflect meaningful legal and cultural pluralism. The key issue is whether local practice is transparent, ethically defensible, patient-centered, and supported by adequate institutional processes.
Practical next steps for ECLS programs
Several concrete steps follow from the ENSURE results. First, ECLS programs should standardize pre-initiation goal setting. Before or immediately after cannulation, teams should document the intended bridge, major markers of success or failure, and anticipated triggers for reassessment.
Second, routine multidisciplinary family meetings should be built into prolonged ECLS care. These meetings should include physicians and nurses and, where available, palliative care specialists. Clear language about uncertainty and possible treatment limits should begin early rather than only when deterioration becomes irreversible.
Third, institutions should develop formal protocols for ECLS discontinuation, including criteria for ethics consultation, symptom management plans at withdrawal, staff debriefing, and documentation standards. Protocols should not replace individualized judgment, but they can reduce avoidable inconsistency.
Fourth, access to ethics support should be expanded. Centers caring for ECLS patients should have timely consultation pathways, not only a distant committee structure. Fifth, palliative care should be integrated earlier in complex ECLS cases, especially when the probability of nonrecovery is rising or conflicts are emerging.
Finally, training should address the emotional and moral dimensions of ECLS. Simulation, communication workshops, and post-case debriefs may help teams manage distress and improve confidence in handling withdrawal discussions.
Conclusion
The ENSURE survey provides one of the clearest multinational snapshots to date of how end-of-life decision-making during ECLS is reported across Europe. Its central message is not merely that practices differ, but that these differences are substantial, patterned, and likely rooted in deeper ethical, cultural, religious, and institutional factors. While 41% of respondents reported discontinuing ECLS with comfort care when goals can no longer be met, this approach was far more common in Northern and Western Europe than in Southern and Eastern Europe, where continued ECLS alongside limitation of other therapies was more frequently reported.
Equally important, the survey reveals a support gap. Ethics resources are not universally available, palliative care integration appears incomplete, and nurses and families are not consistently included in decision-making. For a therapy as intensive and morally complex as ECLS, technical capability alone is insufficient. Programs need ethical infrastructure, communication systems, and palliative frameworks that are as deliberate as their cannulation protocols.
For clinicians and health systems, the study should prompt a practical response: define goals early, reassess them explicitly, involve multidisciplinary teams and families, and ensure that difficult decisions are supported rather than improvised. Reducing unwarranted variation will not eliminate tragedy in ECLS care, but it may improve consistency, protect patient-centered values, and lessen moral distress for the teams who deliver this therapy.
Funding and ClinicalTrials.gov
The abstract provided does not report funding information or a ClinicalTrials.gov registration number. Survey studies of this type are often not registered on ClinicalTrials.gov, but readers should consult the full article for disclosures, funding sources, and ethics approval details.
Citation
Swol J, Supady A, Fleig M, Kelly-Geyer J, Hoskote A, Thiagarajan RR, Polito A. Reported Practices in End-of-Life Decision-Making During Extracorporeal Life Support (ENSURE)-Results From an International European Chapter of the Extracorporeal Life Support Organization Survey. Critical Care Medicine. 2026-06-04. PMID: 42240435. URL: https://pubmed.ncbi.nlm.nih.gov/42240435/
Relevant background literature for context includes guidance and ethics discussions from the Extracorporeal Life Support Organization and critical care societies; readers should refer to the final published article for the authors’ complete reference list.
