Extracorporeal membrane oxygenation (ECMO) is essentially a heart-lung bypass machine that can be used to support certain critically ill neonates. ECMO therapy reached a peak in usage in the mid to late 1980s. At that time, ECMO was most often used for severe complications of persistent pulmonary hypertension, meconium aspiration, congenital diaphragmatic hernia, and sepsis. Since that time, the use of ECMO has decreased, due largely to newer medical advances that have improved the course of these neonates. Whether a nurse works in a Level III ECMO center or a Level I, II, or III NICU, ECMO treatment has become less familiar than it once was. But even though ECMO is used less often, there are times when nothing can take its place. It is important to stay informed so that families of those critically ill newborns who do need ECMO can be educated and supported. This article defines ECMO, discusses when it should be incorporated into the plan of care, describes advances in the NICU that have resulted in the dramatic reduction in the use of ECMO, and provides information and communication strategies to better support the family of a very sick newborn.