Bridges to Nowhere: Navigating Ethical Quandaries That Have Emerged With Novel Approaches to Organ Transplantation

Jordan Francke, MD, MPH

Is a declaration of brain death permanent and irreversible? On Saturday, May 2 at the 2026 Annual Meeting, presented by IARS and SOCCA, during a session entitled, “Ethical Dilemmas of Advanced Invasive Therapies in the ICU: ECMO and Organ Support For Transplant,” Monica Lupei, MD, FCCM, associate professor of anesthesiology and critical care medicine at University of Minnesota, moderated a panel exploring this ethical conundrum and more.

The panel’s first speaker Shahla Siddiqui, MBBS, MSc, an associate professor of anaesthesia, critical care and pain medicine at Harvard Medical School and an attending intensivist at Beth Israel Deaconess Medical Center (BIDMC) framed the issue at hand: decisions in the ICU can be high-stakes, time-pressured, and often unplanned. At times, surrogates and clinicians must make decisions motivated by the patient’s perceived wishes with uncertain prognoses. Dr. Siddiqui posits this can force intensivists into a default decision of initiating invasive therapies unless a clear advanced directive exists, irreversible death is clear, or the risks to the patient outweigh the benefits. Ultimately, patients may be shepherded down a path of being placed on mechanical support devices (such as extracorporeal membrane oxygenation, or ECMO) as a bridge to cardiac or lung transplantation. But when the patient is subsequently deemed not a candidate for transplantation, what happens next? Suddenly the bridge has become the destination. Dr. Siddiqui calls this predicament the “Bridge to Nowhere,” and it can compel both providers and patients’ families into significant moral distress while weighing various next steps.

The second panelist Jai Madhok, MD, MSE, program director for the anesthesiology critical care medicine fellowship program and a clinical associate professor at Stanford University. Dr. Madhok described three different patients, and asked the audience who merited ECMO cannulation. Dr. Madhok suggested that the decision to initiate ECMO varies widely based on providers’ institutional resources (e.g., center expertise, circuit variability, speed of ECMO referrals), as well as the patient’s disease process and comorbidities and the physician’s assessment of their candidacy.

He discussed one possible prediction tool lies in the PRESERVE mortality risk score whose severity has shown strong correlation with 6-month survival in ECMO patients recovering from severe acute respiratory distress syndrome (ARDS). But despite the availability of these scores, many intensivists still struggle with the influence of biases: recency bias (“I know a patient who recently turned a corner after prolonged ECMO”), sunk cost bias (“we’ve already done so much for this patient, it’s hard to give up now”), and so many more. He left the audience with this thought: what about the patient who is on ECMO, who no longer is deemed a transplant candidate, but is laughing with his family and is enjoying watching his favorite sport team on TV? ECMO is not providing a valuable bridge to a definitive solution, but it is providing valuable meaning to this patient’s life. Is that reason enough to continue the therapy until a complication arises?

The last speaker of the panel Louanne Carabini, MD, MA, FASA, medical director for the Northwestern Memorial Hospital Ethics Program and professor of anesthesiology and critical care at Northwestern Medicine. Dr. Carabini focused her discussion on emerging approaches to donations after cardiac death (DCD). Thoracoabdominal normothermic regional perfusion (TA-NRP) is a specialized surgical technique being offered at some transplant centers where the aortic arch vessels are ligated while circulation is restored to the abdominal organs to improve perfusion. However, despite ligating blood flow to the cerebrum, arterial collateral flow cannot be ruled out. Could this new technology potential conflict with the Uniform Determination of Death Act, which defined death as “irreversible cessation of circulatory and respiratory function?”

Some have also argued that it can conflict with the Dead Donor Rule (DDR), but Dr. Carabini clarified that the DDR is commonly misunderstood to insist that organ donation must not precede death when in reality the organ procurement process must not cause death. Nevertheless, this newer surgical approach is being picked up in the lay media and may be fueling a mass exodus of donors from organ registries. Dr. Carabini suggested to build trust from patients and their families, the TA-NRP organ procurement process must be well described and transparent. Furthermore, she also advocated that departments should disseminate education to their providers so that they can “opt out” of participating in these procedures and prevent any possible moral injury from ensuing.