The left ventricular assist device

A Dilemma for Respecting Autonomy: Bridge Technologies and the Hazards of Sequential Decision-Making

Respect for patient autonomy can apply at two levels: ensuring that patient care reflects their considered values and wishes and honoring patient preferences about how to make momentous decisions. Caregivers who seek to respect patient autonomy in the context of some end-of-life decisions face a dilemma. Because these decisions are fraught, patients may prefer to approach them sequentially, only making decisions at the time they arise. However, respecting patients' preferences for a sequential approach can increase the likelihood that surrogates and care teams wind up in situations in which they lack information needed to ensure patients receive care that conforms to their considered values after they are no longer competent to make decisions for themselves. Sequential decision-making can thus conflict with the goal of ensuring care reflects the wishes of patients. After illustrating how this dilemma can arise in the use of life-sustaining "bridge" technologies, we argue that care teams may be warranted in requiring patients to articulate their wishes in an advance care plan before treatment begins. In some cases, care teams may even be permitted to refuse to undertake certain courses of care, unless patients articulate their wishes in an advance care plan.

Learning self-care after left ventricular assist device implantation

The number of heart failure (HF) patients living with a left ventricular assist device (LVAD) as destination therapy is increasing. Successful long-term LVAD support includes a high degree of self-care by the patient and their caregiver, and also requires long-term support from a multidisciplinary team. All three components of self-care deserve special attention once an HF patient receives an LVAD, including activities regarding self-care maintenance (activities related both to the device and lifestyle), self-care monitoring (e.g., monitoring for complications or distress), and self-care management (e.g., handling alarms or coping with living with the device). For patients to perform optimal self-care once they are discharged, they need optimal education that focuses on knowledge and skills through a collaborative, adult learning approach.

Nursing Education and Implications for Left Ventricular Assist Device Destination Therapy

The HeartMate VE Left Ventricular Assist Device (vented electric abdominally positioned pulsatile blood pump; Thoratec Corp., Pleasanton, CA), approved as a permanent support, or destination therapy, by the US Food and Drug Administration in 2002 and Medicare in 2003, is now a potential therapy for numerous patients. Postimplantation nursing care is crucial to the success of left ventricular support device therapy and long-term recipient outcome. Nurses also contribute to cost containment, making this a viable treatment for the facility and the patient. Consequently, nurses must be educated about left ventricular assist device concepts and challenges, the benefits of device placement, intensive care unit and postintensive care unit daily care requirements, and outpatient preparation. This knowledge will enable nurses to provide necessary care and to educate recipients, families, and community health care providers on how to give appropriate posthospital care.

Cardiac transplantation: candidate identification, evaluation, and management

For more than 40 years, cardiac transplantation has been a treatment option for patients with severe heart failure in whom optimal medical management is no longer effective. Critical care nurses are integrally involved in the care of patients with severe heart failure who may benefit from cardiac transplantation and are in a special position to recognize potential candidates for transplantation. Understanding patient selection criteria, the evaluation process, and how patients are managed while awaiting transplantation is key to the knowledge and skills required. It is also important to understand the allocation of donor hearts as part of this process. The waiting period for a suitable donor heart can be long and a patient's condition may deteriorate, requiring an increase in pharmacologic bridges with intravenous inotropic agents or mechanical bridges with circulatory assist devices. Critical care nurses become important as a personal bridge to transplantation through their education of patients and families and helping them cope with their fears during the waiting period. Critical care nurses who possess knowledge of patient selection and organ allocation processes along with the skills of caring for this complex patient population can contribute to better outcomes for patients with heart failure who may be candidates for cardiac transplantation.

Ethics Guidelines for Destination Therapy

The introduction of the left ventricular assist device as a destination therapy for patients with heart failure introduces several ethical issues. These issues are discussed to help destination therapy teams design ethically sound policies and procedures. This article addresses ethical issues pertaining to informed decision making, device failure, and change out, as well as guidelines for deactivation, fair employment of medical and psychosocial criteria, the nature of destination therapy as an elective end-of-life therapy, and advance care planning strategies.

Implantable left ventricular assist devices

The first bridge to transplant with a left ventricular assist device (LVAD) was preformed over 20 years ago. Since that time, the devices have continued to evolve and now patients are being supported with devices as an alternative to transplantation. The primary indication of end-stage heart failure remains the same but increased knowledge about patient selection, the timing of implant, and patient management have contributed to improved outcomes with decreasing adverse events. Multiorgan failure, right ventricular failure, bleeding, infection, thromboembolism, and device malfunction continue to be the most serious threats to long-term survival in these patients. Despite that, patients who do well are now able to be discharged from the hospital and resume relatively normal lives with the devices. The article reviews 3 of the most widely used LVADs for bridge to transplant therapy: the Thoratec; HeartMate vented electric; and the Novacor Left Ventricular Assist System. Indications, mechanism of operation, clinical problems, and out-of-hospital preparation are outlined.

Inquiry in Baccalaureate Nursing Education: Fostering Evidence-Based Practice

With the increasing emphasis on evidence-based nursing practice, nurse educators need to more fully implement teaching strategies that help students gain critical thinking skills related to inquiry and understand the importance of evidence-based nursing practice. Research and scholarship emphases in one baccalaureate nursing program, student-identified benefits, and challenges associated with incorporating inquiry across the curriculum are described in this article. In clinical journal entries, students described the following benefits associated with curricular emphasis on inquiry: increased interest in evidence-based nursing practice and participating in the generation of research; enhanced critical thinking skills through the development of knowledge, experience, and competencies; increased motivation to continue professional growth and development by participating in lifelong learning; the desire to become better consumers of research findings; better understanding of the "real world" of clinical research; and increased desire to pursue graduate studies in nursing. The challenge to promote student growth toward competence in the application of evidence-based principles in clinical practice is ongoing.

Left Ventricular Assist Devices as Destination Therapy

Although an estimated 16,500 Americans annually could benefit from a heart transplant, in 1999 only 2184 heart transplants were performed in the United States. These statistics emphasize the severity of the shortage of available hearts for transplantation. Circulatory support provided by an implantable Left Ventricular Assist Device (LVAD) that meets Food and Drug Administration approval as destination therapy is a promising alternative that impacts patient survival. As medical technology creates smaller implantable battery-powered circulatory assist devices that allow patients to safely live independently in the community, nursing's role must change in response. Long-term LVAD patients require strategic, anticipatory planning for extended care and emergency preparedness for mechanical support. Therefore, practitioners must familiarize themselves with these devices as they care for larger numbers of patients with implanted LVADs who require assessment and treatment of noncardiac problems during their lengthened lifespan.