When a Devastating Event Occurs: Ethical Analysis of a Clinically Challenging Case

Case: A 65-year-old man with a previous medical history of hypertension, hyperlipidemia, and obesity is diagnosed with renal cell carcinoma with associated inferior vena cava (IVC) thrombus and concern for pulmonary metastases. He presents to the OR for nephrectomy and IVC thrombectomy. His intraoperative course is complicated by bleeding and subsequently profound hypoxia and hypotension concerning for pulmonary embolus (PE). Intraoperative transesophageal echocardiogram corroborates the diagnosis of PE. The surgical team proposes initiation of extracorporeal membrane oxygenation (ECMO) and cannulates the patient. Following heparinization, he becomes profoundly coagulopathic, requiring massive transfusion. Postoperatively, he is transferred to the ICU, persistently coagulopathic with ongoing transfusion requirements. He later undergoes a CT angiogram notable for extensive bilateral PEs. He is taken for suction thrombectomy, which is unsuccessful. He remains in the ICU, now with evidence of multisystem organ dysfunction, requiring high levels of oxygen, hemodynamic, and extracorporeal support. In the preoperative period, future...