A qualitative analysis of physician decision making in the use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest

Aim of Study: To prepare for the design of future randomized clinical trials of extracorporeal cardioupulmonary resuscitation (ECPR), we sought to understand physician beliefs regarding the use of ECPR and subsequent management, among physicians who already perform ECPR, as these physicians would be likely to be involved in many planned ECPR trials. Methods: We performed 12 semi-structured interviews of physicians who already perform ECPR across a variety of medical specialties, centers and geographic regions, but all with 10-50+ cases of ECPR experience. We qualitatively analyzed these interview to identify key characteristics of their experience using ECPR, the tensions involved in patient identification, the complications of subsequent management, and their willingness to enroll potential ECPR patients in randomized trials of ECPR. Results: Physicians who routinely perform ECPR have strong beliefs regarding the use of ECPR, and typically have protocols they follow, though they are willing to break these protocols to cannulate young or healthy patients, or patients with immediate pre-hospital CPR and shockable rhythms. We found that physicians lacked equipoise to randomize these types of patients to continued conventional CPR. Future RCTs might be successful in enrolling older patients, younger patients without immediate pre-hospital care/bystander CPR, or patients with obvious comorbidities. Conclusions: RCTs for ECPR will need to avoid targeting patients in whom physicians feel strongly compelled to do ECPR or not do ECPR, instead identifying the middle range of patients in whom the physicians consider ECPR reasonable, but not required or contraindicated.