Ethical Challenges With Deactivation of Durable Mechanical Circulatory Support at the End of Life

Rady, Mohamed Y.; Verheijde, Joseph L.

doi:10.1177/0885066611432415

Cited by 36 publications

(32 citation statements)

References 64 publications

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“…Indeed, device deactivation results in the death of the patient, usually within hours [30,31]. Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions supported by an LVAD.…”

Section: End Of Lifementioning

confidence: 99%

“…Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions supported by an LVAD. Examples of such lethal conditions include refractory circulatory shock, overwhelming infections, multiple organ failure, refractory hypoxia, irreversible coma, stroke with irreversible neurological lesions or catastrophic device failure [30,31].…”

Section: End Of Lifementioning

confidence: 99%

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Understanding Left Ventricular Assist Devices

et al. 2018

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Background/Aims: Long-term mechanical assist devices are now commonly used in the treatment of severe heart failure to unload the failing ventricle, maintain sufficient end-organ perfusion and improve functional capacity. Depending on the assisted ventricles, 3 categories of long-term assist devices are available: left ventricular assist device (LVAD), biventricular assist device and total artificial heart. Improvements in technology, especially the advent of smaller, durable continuous flow pumps, have led to the use of LVADs in a much broader population of patients in the last 10 years. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. Regarding this growing number of patients with LVAD, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management. Methods: We performed a narrative review of relevant medical literature regarding the physiology of patients with LVAD and management of common complications relevant to the critical care physicians. Results: The most frequent complications occurring in the LVAD patients after the post-operative period are bleeding, driveline infections, thrombosis, device malfunction, right ventricular failure and arrhythmias. Bleeding is the most frequent adverse event in LVAD due to a combination of anticoagulation and acquired von Willebrand disease secondary to shear stress produced within the pump. Their management includes antiplatelet therapy arrest, reduction of the anticoagulation regimen and specific therapy if feasible. Infection is the second most common cause of death after cardiac failure in LVAD patients. All infections must be aggressively treated to avoid seeding the device. Device thrombosis can develop even when patients are adequately anticoagulated and taking antiplatelet therapy because the LVAD is responsible for a chronic hypercoagulable state. Conclusion: Management of these unique patients in the ICU is best accomplished with a multidisciplinary team that includes specialists in advanced heart failure, LVAD nurse coordinators and intensivists.

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Section: End Of Lifementioning

confidence: 99%

Section: End Of Lifementioning

confidence: 99%

Understanding Left Ventricular Assist Devices

et al. 2018

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“…[28] Medicare and Medicaid in the US have stipulated that centres implanting VADs as a destination therapy include a PC specialist as a member of the team, due to the fact that durable mechanical circulatory support might significantly alter EoL trajectory (www.cms.gov/medicare-coverage-database/details/nca-proposed-decisionmemo.aspx?NCAId=268).…”

Section: Need For Better Communicationmentioning

confidence: 99%

End-of-life matters in chronic heart failure patients

Sobański¹,

Jaarsma²,

Krajnik³

2014

Current Opinion in Supportive &Amp; Palliative Care

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Purpose of reviewUntil recently, concepts of care for people with heart failure (HF) had rarely included preparation for unavoidable imminent death or caring for the dying.The purpose of this review is to provide an update on current end-of-life (EoL) issues specific to HF patients. Recent findingsMortality in the HF population remains high, especially short after the first acute HF hospitalisation. Patients with systolic HF die more frequently from progressive HF or sudden cardiac death (SCD); patients with diastolic HF for non-cardiovascular reasons and SCD. The mode of haemodynamic decline leading to HF death can be characterised by low cardiac output with or without secondary end-organ dysfunction, congestion or a combination of both. A new model of EoL trajectories has been proposed which takes into account this influence on the prognosis of HF and comorbidities. Advance care planning for patients with implanted cardiac devices has been shown to be unsatisfactory. A recent strategy for managing implantable cardioverter defibrillators in patients approaching death is presented. Summary There is an emerging need to define specific challenges for EoL care for approaching death in HF patients. More research and education are needed to improve care for dying HF patients, including those with implanted cardiac devices.

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“…6,15,18,[21][22][23][24][25] It is important to note that although an ethical consensus is taking shape, some ethicists remain opposed to device deactivation in many circumstances. 20,26 It is also not uncommon for clinicians to object to deactivation of a VAD. Usually, the argument proceeds as follows: the VAD is a long-term, continuous, constitutive (i.e., it takes over a function that the body can no longer perform) life-sustaining intervention.…”

Section: Commentarymentioning

confidence: 99%