Ethical Analysis of Withdrawing Total Artificial Heart Support

DeMartino, Erin S.; Wordingham, Sara E.; Sulmasy, Daniel P.; Stulak, John M.; Boilson, Barry A.; Fuechtmann, Kayla R.; Singh, Neeraj; Pajaro, Octavio E.; Mueller, Paul S.

doi:10.1016/j.healun.2016.01.773

Cited by 3 publications

(8 citation statements)

References 17 publications

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“…In some organisations, such as the UK National Health Service, only BTT‐LVAD might be offered (British Heart Foundation, ). However, all patients are at risk of severe or catastrophic complications and there are specific ethical concerns with such devices at the end of life (DeMartino, et al, ; Rady, Verheijde, & and, ; Simon & Fischbach, ). When compared to other patients with advanced heart failure, shared decision‐making via advanced care planning is often not broached but where it is it seems to have a positive effect.…”

Section: Introductionmentioning

confidence: 99%

To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: A review

Delmaczynska

Newham

2019

Journal of Clinical Nursing

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Aims and objectives To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: a review. Background End‐stage heart failure is associated with significant symptom burden at rest. Left ventricular assist devices are not curative; nevertheless, they alleviate symptoms and prolong survival. Evidence suggests that most patients with left ventricular assist devices and their families do not have open discussions regarding end‐of‐life wishes until catastrophic complications arise. Therefore, it is important to understand reasons for this, so healthcare professionals such as nurses can facilitate the process. Design A mixed‐studies integrative review with a narrative synthesis of the evidence. PRISMA guidelines were followed for reporting systematic qualitative reviews. Method A search of four electronic data in January 2018 and a hand search yielded 139 citations; seven studies met the review eligibility criteria. Methodological quality of the selected studies was evaluated, and data were extracted and compiled. Results Three themes were identified: prevalence and feasibility of advanced care planning, advance care planning developed for patients with device support, patients’ and caregivers’ perceptions of advanced care planning discussions. Advanced care planning is underused routinely implemented in left ventricular device centres. Pre‐implantation advanced care planning is feasible and results in the highest rate of documented advance decisions which are useful for both patients and their loved ones in cases of complications. Conclusion Strong evidence that left ventricular assist‐specific advanced care planning is recommended for all left ventricular assist device patients to enable their treatment preferences in case of incurable complications. Palliative care services should collaborate with nurses in designing and facilitating advanced care planning for delisted transplant patients. Patients with left ventricular devices awaiting heart transplant and those waiting for myocardium healing are underrepresented in the current studies. Research on the optimal timing of advanced care planning in these groups of patients is indicated. Relevance for clinical practice There is a need for improved approaches to advanced care planning for and with people with left ventricular devices.

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Section: Introductionmentioning

confidence: 99%

To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: A review

Delmaczynska

Newham

2019

Journal of Clinical Nursing

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“…Second, death that follows carrying out a patient's or surrogate's informed request to withdraw an unwanted LST is due to the patient's underlying disease and pathophysiology. In contrast, in physician-assisted suicide and euthanasia, death that follows taking, or being administered, a lethal prescription is due to the lethal prescription-a newly introduced pathology-not the underlying disease (4,5,10,(15)(16)(17)20).…”

Section: Is Withdrawing Mechanical Circulatory Support a Form Of Phys...mentioning

confidence: 99%

“…However, it is widely accepted that carrying out informed requests to withdraw other continuous and constitutive LSTs (e.g., mechanical ventilation, artificial nutrition and hydration, etc.) is ethically and legally permissible (4)(5)(6)25).…”

Section: Is Mechanical Circulatory Support a Morally Unique Treatment?mentioning

confidence: 99%

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Ethical and Legal Concerns Associated With Withdrawing Mechanical Circulatory Support: A U.S. Perspective

Mueller

2022

Front. Cardiovasc. Med.

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Hundreds of thousands of Americans have advanced heart failure and experience severe symptoms (e. g., dyspnea) with minimal exertion or at rest despite optimal management. Although heart transplant is an effective treatment for advanced heart failure, the demand for organs far exceeds the supply. Another option for these patients is mechanical circulatory support (MCS) provided by devices such as the ventricular assist device and total artificial heart. MCS alleviates symptoms, prolongs life, and provides a “bridge to transplant” or a decision regarding future management such as “destination therapy,” in which the patient receives lifelong MCS. However, a patient receiving MCS, or his/her surrogate decision-maker, may conclude ongoing MCS is burdensome and no longer consistent with the patient's healthcare-related values, goals, and preferences and, as a result, request withdrawal of MCS. Likewise, the patient's clinician and care team may conclude ongoing MCS is medically ineffective and recommend its withdrawal. These scenarios raise ethical and legal concerns. In the U.S., it is ethically and legally permissible to carry out an informed patient's or surrogate's request to withdraw any treatment including life-sustaining treatment (LST) if the intent is to remove a treatment perceived by the patient as burdensome and not to terminate intentionally the patient's life. Under these circumstances, death that follows withdrawal of the LST is due to the underlying disease and not a form of physician-assisted suicide or euthanasia. In this article, frequently encountered ethical and legal concerns regarding requests to withdraw MCS are reviewed: the ethical and legal permissibility of withholding or withdrawing LSTs from patients who no longer want such treatments; what to do if the clinician concludes ongoing LST will not result in achieving clinical goals (i.e., medically ineffective); responding to requests to withdraw LST; the features of patients who undergo withdrawal of MCS; the rationale for advance care planning in patients being considered for, or receiving, MCS; and other related topics. Notably, this article reflects a U.S. perspective.

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“…In WLST, life support is withdrawn with the intent of reducing burden, suffering and loss of dignity associated with these treatments (13,14). Withdrawing life-sustaining therapies allows the primary problem to progress, even to death, and pain and anxiety are treated without artificially hastening death (16,17).…”

Section: Withdrawal Of Life-sustaining Therapy and Hastening Deathmentioning

confidence: 99%

Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies

Kirsch

Balit

et al. 2018

Pediatric Critical Care Medicine

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As part of the invited supplement on Death and Dying in the PICU, we reviewed ethical, cultural, and social considerations for the bedside healthcare practitioner prior to engaging with children and families in decisions about limiting therapies, withholding, or withdrawing therapies in a PICU. Clarifying beliefs and values is a necessary prerequisite to approaching these conversations. Striving for medical consensus is important. Discussion, reflection, and ethical analysis may determine a range of views that may reasonably be respected if professional disagreements persist. Parental decisional support is recommended and should incorporate their information needs, perceptions of medical uncertainty, child's condition, and their role as a parent. Child's involvement in decision making should be considered, but may not be possible. Culturally attuned care requires early examination of cultural perspectives before misunderstandings or disagreements occur. Societal influences may affect expectations and exploration of such may help frame discussions. Hospital readiness for support of social media campaigns is recommended. Consensus with family on goals of care is ideal as it addresses all parties' moral stance and diminishes the risk for superseding one group's value judgments over another. Engaging additional supportive services early can aid with understanding or resolving disagreement. There is wide variation globally in ethical permissibility, cultural, and societal influences that impact the clinician, child, and parents. Thoughtful consideration to these issues when approaching decisions about limitation or withdrawal of life-sustaining therapies will help to reduce emotional, spiritual, and ethical burdens, minimize misunderstanding for all involved, and maximize high-quality care delivery.

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Ethical Analysis of Withdrawing Total Artificial Heart Support

Cited by 3 publications

References 17 publications

To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: A review

To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: A review

Ethical and Legal Concerns Associated With Withdrawing Mechanical Circulatory Support: A U.S. Perspective

Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies

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