Ethical Analysis of Withdrawing Ventricular Assist Device Support

Abstract

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

Little Hope for Medical Futility

“…12 When major medical procedures are initiated, there should always be some discussion of when they will be stopped. 13,14 Patients, family, and friends who know that a left ventricular assist device is a destination therapy and that the destination is a grim one or that dialysis when started and helpful will possibly be stopped at some point before death are far more likely to accept the limits of medicine than those who see a technologic treatment started without any mention that it may well be stopped.…”

Palliative Medicine Consultation for Preparedness Planning in Patients Receiving Left Ventricular Assist Devices as Destination Therapy

“…Nevertheless, during our first year, 13 (68%) of 19 received PM consultation, which is an improvement compared with our prior experience of 0 of 36 patients receiving proactive PM consultation. 21 Before this endeavor, only 5 (14%) of 36 DT patients received PM consultation at any point in their care. 21 This finding is despite the fact that half of these 36 patients had died since the first implantation, with a median survival of 172 days (range, 1-1030 days) for all deceased DT patients at our institution from March 2003 to January 2009.…”

“…18 Also, protocols and processes regarding LVAD management and comfort at the end of life are often lacking 7,17 ; hence, ethical quandaries (eg, withdrawal of device support) may arise. 19,20 To avoid situations in which advance care wishes are unclear or unknown, palliative medicine (PM) consultation has been suggested 8,17,[21][22][23] to address end-of-life preferences, facilitate advance care planning, manage symptoms, and maximize QOL. Several authors have called for PM involvement in patients with advanced heart disease to improve health status and QOL, [24][25][26][27][28][29] and a recent randomized study of early palliative care vs standard care in advanced lung cancer has demonstrated improved QOL, improved mood, and survival benefit.…”

Current Options and Practices in Long-Term Ventricular Assist Devices

“…As VAD placement is discussed with patient and family, end of life issues must be addressed, not only because of the seriousness of the current illness and the potential mortality of the operation but also because the treatment equates to mobile life support [52 • ]. While VADs have repeatedly been shown to increase quality of life, the possibility of a patient eventually asking to withdraw this life-prolonging care has been seen in multiple studies to be approximately 20 % [51,53]. While some believe that once implanted a VAD becomes one with the patient and deactivating it amounts to euthanasia, most ethicists agree that deactivation of the VAD equates to withdrawal of life support and the terminal insult is that of heart failure, not the deactivation of the VAD by the physician [54].…”

“…As the medical community continues to develop life-saving technology, ethical dilemmas frequently arise, and VADs are rarely considered in advanced directives [51]. As VAD placement is discussed with patient and family, end of life issues must be addressed, not only because of the seriousness of the current illness and the potential mortality of the operation but also because the treatment equates to mobile life support [52 • ].…”