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OBJECTIVE: To describe a series of patients with heart failure supported with a ventricular assist device (VAD) who requested (or whose surrogates requested) withdrawal of VAD support and the legal and ethical aspects pertaining to these requests. PATIENTS AND METHODS:We retrospectively reviewed the medical records of patients at Mayo Clinic, Rochester, MN, from March 1, 2003, through January 31, 2009, who requested (or whose surrogates requested) withdrawal of VAD support and for whom the requests were fulfilled. We then explored the legal and ethical permissibility of carrying out such requests. RESULTS:The median age of the 14 patients identified (13 men, 1 woman) was 57 years. Requests were made by 2 patients and 12 surrogates. None of the patients' available advance directives mentioned the VAD. For 11 patients, multidisciplinary care conferences were held before withdrawal of VAD support. Only 1 patient had an ethics consultation. All 14 patients died within 1 day of withdrawal of VAD support. CONCLUSION:Patients have the right to refuse or request the withdrawal of any unwanted treatment, and we argue that this right extends to VAD support. We also argue that the cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia. Therefore, patients with heart failure supported with VADs or their surrogates may request withdrawal of this treatment. In our view, carrying out such requests is permissible in accordance with the principles that apply to withdrawing other life-sustaining treatments. Proc. 2010;85(9):791-797 AD = advance directive; BTT = bridge to (cardiac) transplant; DT = destination therapy; ICD = implantable cardioverter-defibrillator; LVAD = left VAD; VAD = ventricular assist device Mayo Clin

Patients who undergo implantation of left ventricular assist devices (LVADs) often have improved quality of life, but may eventually succumb to their heart failure and/or sustain LVAD-related complications. In end-of-life situations, decisions must be made about when to deactivate LVAD support. Previous studies have demonstrated that end-of-life planning, particularly with the use of advance directives (ADs), can clarify patients' end-of-life preferences when they are unable to speak for themselves. However, many patients do not have ADs, and among patients who do, the ADs may lack useful information on how to guide care surrogates and clinicians regarding patients' preferences on life-sustaining treatments. The authors retrospectively reviewed the charts of 68 patients with advanced heart failure (56 men [82%]; mean [standard deviation] age, 59.0 ± 12.2 years) who underwent LVAD implantation between March 2003 and January 2009. The indication for the LVAD was destination therapy in 36 (53%) patients and bridge to heart transplant in 32 (47%) patients. Overall, 32 (47%) patients had ADs of varying types; 25 (78%) ADs were completed before LVAD implantation. Although life-sustaining treatments (eg, tube feeding, cardiopulmonary resuscitation, mechanical ventilation, and hemodialysis) were mentioned, none explicitly mentioned the LVAD or withdrawal of LVAD support at the end of life. We hypothesize that if instructions regarding LVAD management in ADs are explicit, surrogate and clinician distress may decrease, and ethical dilemmas may be avoided.

Left ventricular assist devices as destination therapy (DT) improve quality of life for many patients with advanced heart failure. However, DT can be associated with risks such as infection, bleeding, and stroke, and may impose psychosocial strain on patients and caregivers. Furthermore, patients treated with DT eventually will die with their device in place whether death is related to the device or not. In response to these concerns, palliative medicine consultation has been suggested with standard DT care to improve focus on quality of life, symptom management, and end-of-life planning. This article reviews key issues associated with caring for patients with DT, including psychosocial, quality-of-life, caregiving, and ethical issues, and discusses end-of-life management of patients with DT, including practical considerations, but moreover, review topics regarding communication, symptom management, and provision of appropriate comfort care.