Ethical dilemmas in COVID-19 patients awaiting lung transplantation on extracorporeal membrane oxygenation

Abstract Background: Extracorporeal membrane oxygenation (ECMO) may serve as a bridge to successful lung transplantation (LT) in selected patients with coronavirus disease 19 (COVID- 19) pneumonia. Compliance with the recognized LT criteria however, may be impossible to be met in this particular and extremely challenging group of patients. This situation create huge moral and ethical dilemmas. To indicate this, we decided to explore this difficult topic and present how non-compliance to the recognized LT criteria enabled us to perform three successful and life-saving LT procedures in COVID-19 patients. Methods: Data of all consecutive patients on ECMO support as rescue treatment for COVID- 19 pneumonia, awaiting LT at SCHD between October 1, 2020 and May 31, 2021 were reviewed. Results: 18 patients on ECMO entered the list for LT at SCHD (mean age: 40.5 ± 5.6 years, range 28–48 years). Mean duration of ECMO was 29.6 ± 15.5 days (range 6–71 days). 11 patients died: either during LT (n = 3), post-LT (n = 1), or on ECMO awaiting LT (n = 7). The overall mortality rate in this group was 61.1%. Survivors (n=7) were either successfully transplanted (n = 3) or weaned from ECMO (n = 4). In the medical literature, there are several enthusiastic case reports describing successful LTs, however there might be a significant publication bias in this area, as failed procedures probably remain largely under-reported. There are no data to indicate the right time for LT in post-COVID-19 patients. Experts in this field require minimum recovery period of 4 weeks to exclude native lung recovery, active participation in physical rehabilitation and the possibility of providing informed consent to proceed with LT. All these conditions were impossible to be met in our patients awaiting LT on ECMO support. Conclusions: Traditional lung transplantation criteria are difficult to be applied in COVID-19 patients requiring ECMO support due to medical and ethical reasons. Performing LT without prior consent of patients violates the ethical principles of solid organ transplants, but may be life-saving in some patients.