When ECMO can no longer bridge: a narrative review and proposed consent template

Background Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with cardiac or respiratory failure as a bridge to recovery, transplantation, or durable mechanical circulatory support. When these goals cannot be achieved, withdrawal of ECMO presents complex clinical and ethical challenges, yet standardized guidance remains limited. Methods We performed a narrative review of the literature from ECMO inception through June 2026 using PubMed, Embase, Scopus, and JSTOR. Studies, guidelines, registry analyses, and commentaries addressing ECMO withdrawal, transplant eligibility, communication, and end-of-life care in adults were included. Results Withdrawal of ECMO is common, particularly among patients receiving VA ECMO, but practices vary considerably across institutions. Decisions are typically made by surrogate decision-makers after determination that recovery, transplantation, or durable mechanical support is no longer feasible. Current evidence emphasizes the importance of multidisciplinary decision-making, longitudinal goals-of-care discussions, proactive symptom management, and structured approaches to compassionate ECMO discontinuation. We also identify substantial gaps in evidence regarding consent, withdrawal protocols, and clinician support. Conclusions ECMO withdrawal remains an understudied area with institutional variation and without standardized best practices. We propose reframing ECMO consent as an ongoing goals-of-care process and present an ECMO-specific consent template to improve communication, align expectations, and support compassionate, patient-centered end-of-life care. Further research is needed to inform evidence-based guidelines.