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Mueller PS. Ethical and Legal Concerns Associated With Withdrawing Mechanical Circulatory Support: A U.S. Perspective. Front Cardiovasc Med 2022; 9:897955. [PMID: 35958394 PMCID: PMC9360408 DOI: 10.3389/fcvm.2022.897955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
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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Unlike Diamonds, Defibrillators Aren't Forever: Why It Is Sometimes Ethical to Deactivate Cardiac Implantable Electrical Devices. Camb Q Healthc Ethics 2019; 28:338-346. [PMID: 31113519 DOI: 10.1017/s096318011900015x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Colletta KL, Bar B, Liebo MJ, Borys E, Schneck MJ, Gomez CR. Thrombectomy of Ventricular Assist Device-Originated Embolic Stroke: A Clinical Decision Model. J Neuroimaging 2019; 29:423-430. [PMID: 30994961 DOI: 10.1111/jon.12621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE The use of ventricular assist devices (VADs) for the treatment of heart failure has become increasingly common. These patients have a considerable risk of cerebral embolism. We describe such a patient and his successful treatment by thrombectomy, compare his attributes with those previously published, and describe the construct of a clinical decision model, whose results bear practical implications for patient management. METHODS The details of our patient and his treatment are presented, followed by a literature review of all previously reported similar cases. Using this information, as well as that available from published series, we constructed a probabilistic decision tree, completed all calculations (ie, "folding back"), and, in order to assess the strength of the results, subjected them to multiple independent sensitivity analyses of each of the variables. RESULTS The therapeutic success of our case, the 14th reported to date, when combined with previous reports, shows: (1) recanalization times of 184 minutes, (2) "successful" recanalization (ie, TICI = 2b or 3) achieved in 71% of procedures, (3) ultimate functional outcome (ie, mRS = 0-2) achieved in 57% patients, and (4) ultimate successful heart transplantations in 66% of cases. The clinical decision model showed the predicted utility of thrombectomy to be superior to conservative management (3.33 QALY vs. 2.56 QALY, respectively). The sensitivity analyses support the validity of these results. CONCLUSIONS In conclusion, thrombectomy appears to be a safe and effective method (and often the only viable one) for urgent treatment of patients with VAD-originated cerebral embolism.
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Affiliation(s)
- Kalea L Colletta
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine
| | - Barak Bar
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine
| | - Max J Liebo
- Division of Cardiology, Department of Internal Medicine, Loyola University Chicago, Stritch School of Medicine
| | - Ewa Borys
- Department of Pathology, Loyola University Chicago, Stritch School of Medicine
| | - Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine
| | - Camilo R Gomez
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine.,Neuroendovascular Surgery Program, Loyola University Chicago, Stritch School of Medicine
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Cook JL, Colvin M, Francis GS, Grady KL, Hoffman TM, Jessup M, John R, Kiernan MS, Mitchell JE, Pagani FD, Petty M, Ravichandran P, Rogers JG, Semigran MJ, Toole JM. Recommendations for the Use of Mechanical Circulatory Support: Ambulatory and Community Patient Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e1145-e1158. [PMID: 28559233 DOI: 10.1161/cir.0000000000000507] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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DeMartino ES, Wordingham SE, Stulak JM, Boilson BA, Fuechtmann KR, Singh N, Sulmasy DP, Pajaro OE, Mueller PS. Ethical Analysis of Withdrawing Total Artificial Heart Support. Mayo Clin Proc 2017; 92:719-725. [PMID: 28473036 PMCID: PMC5653372 DOI: 10.1016/j.mayocp.2017.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/21/2016] [Accepted: 01/16/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To describe the characteristics of patients who undergo withdrawal of total artificial heart support and to explore the ethical aspects of withdrawing this life-sustaining treatment. PATIENTS AND METHODS We retrospectively reviewed the medical records of all adult recipients of a total artificial heart at Mayo Clinic from the program's inception in 2007 through June 30, 2015. Management of other life-sustaining therapies, approach to end-of-life decision making, engagement of ethics and palliative care consultation, and causes of death were analyzed. RESULTS Of 47 total artificial heart recipients, 14 patients or their surrogates (30%) requested withdrawal of total artificial heart support. No request was denied by treatment teams. All 14 patients were supported with at least 1 other life-sustaining therapy. Only 1 patient was able to participate in decision making. CONCLUSION It is widely held to be ethically permissible to withdraw a life-sustaining treatment when the treatment no longer meets the patient's health care-related goals (ie, the burdens outweigh the benefits). These data suggest that some patients, surrogates, physicians, and other care providers believe that this principle extends to the withdrawal of total artificial heart support.
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Affiliation(s)
- Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Sara E Wordingham
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, AZ
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Barry A Boilson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Daniel P Sulmasy
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| | - Octavio E Pajaro
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ
| | - Paul S Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
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Abstract
Many seriously ill geriatric patients are at higher risk for perioperative morbidity and mortality, and incorporating proactive palliative care principles may be appropriate. Advanced care planning is a hallmark of palliative care in that it facilitates alignment of the goals of care between the patient and the health care team. When these goals conflict, perioperative dilemmas can occur. Anesthesiologists must overcome many cultural and religious barriers when managing the care of these patients. Palliative care is gaining ground in several perioperative populations where integration with certain patient groups has occurred. Geriatric anesthesiologists must be aware of how palliative care and hospice influence and enhance the care of elderly patients.
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Affiliation(s)
- Allen N Gustin
- Department of Anesthesiology, Stritch School of Medicine, Loyola University Medicine, 2160 South 1st Avenue, Building 103, Room-3102, Chicago, IL 60153, USA.
| | - Rebecca A Aslakson
- Department of Anesthesiology and Critical Care Medicine, Palliative Medicine Program at the Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, 1800 Orleans Street, Meyer 289, Baltimore, MD 21287, USA; Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of Public Health, 1800 Orleans Street, Meyer 289, Baltimore, MD 21287, USA
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Willemsen D, Cordes C, Bjarnason-Wehrens B, Knoglinger E, Langheim E, Marx R, Reiss N, Schmidt T, Workowski A, Bartsch P, Baumbach C, Bongarth C, Phillips H, Radke R, Riedel M, Schmidt S, Skobel E, Toussaint C, Glatz J. [Rehabilitation standards for follow-up treatment and rehabilitation of patients with ventricular assist device (VAD)]. Clin Res Cardiol Suppl 2016; 11 Suppl 1:2-49. [PMID: 26882905 DOI: 10.1007/s11789-015-0077-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The increasing use of ventricular assist devices (VADs) in terminal heart failure patients provides new challenges to cardiac rehabilitation physicians. Structured cardiac rehabilitation strategies are still poorly implemented for this special patient group. Clear guidance and more evidence for optimal modalities are needed. Thereby, attention has to be paid to specific aspects, such as psychological and social support and education (e.g., device management, INR self-management, drive-line care, and medication).In Germany, the post-implant treatment and rehabilitation of VAD Patients working group was founded in 2012. This working group has developed clear recommendations for the rehabilitation of VAD patients according to the available literature. All facets of VAD patients' rehabilitation are covered. The present paper is unique in Europe and represents a milestone to overcome the heterogeneity of VAD patient rehabilitation.
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Affiliation(s)
- Detlev Willemsen
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland.
| | - C Cordes
- Gollwitzer-Meier-Klinik, Bad Oeynhausen, Deutschland
| | - B Bjarnason-Wehrens
- Institut für Kreislaufforschung und Sportmedizin, Deutsche Sporthochschule Köln, Köln, Deutschland
| | | | - E Langheim
- Reha-Zentrum Seehof der DRV-Bund, Teltow, Deutschland
| | - R Marx
- MediClin Fachklinik Rhein/Ruhr, Essen, Deutschland
- Universität Witten/Herdecke, Witten, Deutschland
| | - N Reiss
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - T Schmidt
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - A Workowski
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - P Bartsch
- Schüchtermann-Klinik, Ulmenalle 5-11, 49214, Bad Rothenfelde, Deutschland
| | - C Baumbach
- Herz- und Gefäßzentrum Bad Bevensen, Bad Bevensen, Deutschland
| | - C Bongarth
- Klinik Höhenried, Bernried am Starnberger See, Deutschland
| | - H Phillips
- Reha Parcs Steinhof, Erkrath, Deutschland
| | - R Radke
- Christiaan-Barnard-Klinik, Dahlen-Schmannewitz, Dahlen, Deutschland
| | - M Riedel
- Klinik Fallingbostel, Bad Fallingbostel, Deutschland
| | - S Schmidt
- Gollwitzer-Meier-Klinik, Bad Oeynhausen, Deutschland
| | - E Skobel
- Rehaklinik "An der Rosenquelle", Aachen, Deutschland
| | - C Toussaint
- m&i Fachklinik Herzogenaurach, Herzogenaurach, Deutschland
| | - J Glatz
- Reha-Zentrum Seehof der DRV-Bund, Teltow, Deutschland
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Al-Mufti F, Bauerschmidt A, Claassen J, Meyers PM, Colombo PC, Willey JZ. Neuroendovascular Interventions for Acute Ischemic Strokes in Patients Supported with Left Ventricular Assist Devices: A Single-Center Case Series and Review of the Literature. World Neurosurg 2015; 88:199-204. [PMID: 26739903 DOI: 10.1016/j.wneu.2015.12.061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND With the shortage of donor hearts, increasingly more patients with end-stage heart failure are implanted with left ventricular assist devices (LVADs). LVADs are associated with a significant risk of developing acute ischemic strokes (AISs). Very little is known on about the management of AIS in patients with LVAD, especially with regard to the safety and efficacy of neuroendovascular techniques. METHODS We identified 5 patients with heart failure and LVAD implants who developed AIS and underwent neuroendovascular interventions at Columbia University Medical Center. Their cases were reviewed for the safety, efficacy of the interventions, and potential complications. RESULTS There were no significant complications from the interventions. In all 5 cases, there was at least a 4-point improvement in the National Institutes of Health Stroke scale and none of the cases developed symptomatic hemorrhage. Two patients had substantial improvement and received cardiac transplantations. CONCLUSIONS Neuroendovascular intervention is safe and feasible in patients with LVAD and may potentially contribute to improving the outcome of a disease that has a poor natural history. Further study is recommended.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Columbia University Medical Center, New York, New York, USA.
| | - Andrew Bauerschmidt
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, New York, USA; Department of Neurosurgery, Columbia University Medical Center, New York, New York, USA
| | - Philip M Meyers
- Department of Neurosurgery, Columbia University Medical Center, New York, New York, USA; Department of Radiology, Columbia University Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Department of Internal Medicine-Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Joshua Z Willey
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
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O'Neill BJ, Kazer MW. Destination to nowhere: a new look at aggressive treatment for heart failure--a case study. Crit Care Nurse 2015; 34:47-55; quiz 56. [PMID: 24692465 DOI: 10.4037/ccn2014442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Approximately 5.7 million people in the United States experience heart failure, and about 670 000 new cases are diagnosed annually. Patients who are ineligible for heart transplant may benefit from a left ventricular assist device. These devices have provided patients with an increased life span, but eventually patients die of the underlying heart disease. This case study illustrates the appropriate use of palliative care teams to address preparedness planning and help decrease moral distress among nursing staff. (Critical Care Nurse. 2014; 34[2]:47-56).
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Swetz KM, Kamal AH, Matlock DD, Dose AM, Borkenhagen LS, Kimeu AK, Dunlay SM, Feely MA. Preparedness planning before mechanical circulatory support: a "how-to" guide for palliative medicine clinicians. J Pain Symptom Manage 2014; 47:926-935.e6. [PMID: 24094703 DOI: 10.1016/j.jpainsymman.2013.06.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/29/2013] [Accepted: 06/14/2013] [Indexed: 11/29/2022]
Abstract
The role of palliative medicine in the care of patients with advanced heart failure, including those who receive mechanical circulatory support, has grown dramatically in the last decade. Previous literature has suggested that palliative medicine providers are well poised to assist cardiologists, cardiothoracic surgeons, and the multidisciplinary cardiovascular team with promotion of informed consent and initial and iterative discussions regarding goals of care. Although preparedness planning has been described previously, the actual methods that can be used to complete a preparedness plan have not been well defined. Herein, we outline several key aspects of this approach and detail strategies for engaging patients who are receiving mechanical circulatory support in preparedness planning.
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Affiliation(s)
- Keith M Swetz
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | | | - Ann Marie Dose
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn S Borkenhagen
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ashley K Kimeu
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon M Dunlay
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Molly A Feely
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Swetz KM, Freeman MR, AbouEzzeddine OF, Carter KA, Boilson BA, Ottenberg AL, Park SJ, Mueller PS. Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist devices as destination therapy. Mayo Clin Proc 2011; 86:493-500. [PMID: 21628614 PMCID: PMC3104909 DOI: 10.4065/mcp.2010.0747] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the benefit of proactive palliative medicine consultation for delineation of goals of care and quality-of-life preferences before implantation of left ventricular assist devices as destination therapy (DT). PATIENTS AND METHODS We retrospectively reviewed the cases of patients who received DT between January 15, 2009, and January 1, 2010. RESULTS Of 19 patients identified, 13 (68%) received proactive palliative medicine consultation. Median time of palliative medicine consultation was 1 day before DT implantation (range, 5 days before to 16 days after). Thirteen patients (68%) completed advance directives. The DT implantation team and families reported that preimplantation discussions and goals of care planning made postoperative care more clear and that adverse events were handled more effectively. Currently, palliative medicine involvement in patients receiving DT is viewed as routine by cardiac care specialists. CONCLUSION Proactive palliative medicine consultation for patients being considered for or being treated with DT improves advance care planning and thus contributes to better overall care of these patients. Our experience highlights focused advance care planning, thorough exploration of goals of care, and expert symptom management and end-of-life care when appropriate.
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Affiliation(s)
- Keith M Swetz
- Palliative Medicine Program, Division of General Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Brush S, Budge D, Alharethi R, McCormick AJ, MacPherson JE, Reid BB, Ledford ID, Smith HK, Stoker S, Clayson SE, Doty JR, Caine WT, Drakos S, Kfoury AG. End-of-life decision making and implementation in recipients of a destination left ventricular assist device. J Heart Lung Transplant 2011; 29:1337-41. [PMID: 20817564 DOI: 10.1016/j.healun.2010.07.001] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 05/24/2010] [Accepted: 07/02/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The use of left ventricular assist devices (LVADs) as destination therapy (DT) is increasing and has proven beneficial in prolonging survival and improving quality of life in select patients with end-stage heart failure. Nonetheless, end-of-life (EOL) issues are inevitable and how to approach them underreported. METHODS Our DT data registry was queried for eligible patients, defined as those individuals who actively participated in EOL decision making. The process from early EOL discussion to palliation and death was reviewed. We recorded the causes leading to EOL discussion, time from EOL decision to withdrawal and from withdrawal to death, and location. Primary caregivers were surveyed to qualify their experience and identify themes relevant to this process. RESULTS Between 1999 and 2009, 92 DT LVADs were implanted in 69 patients. Twenty patients qualified for inclusion (mean length of support: 833 days). A decrease in quality of life from new/worsening comorbidities usually prompted EOL discussion. Eleven patients died at home, 8 in the hospital and 1 in a nursing home. Time from EOL decision to LVAD withdrawal ranged from <1 day to 2 weeks and from withdrawal until death was <20 minutes in all cases. Palliative care was provided to all patients. Ongoing assistance from the healthcare team facilitated closure and ensured comfort at EOL. CONCLUSIONS With expanding indications and improved technology, more DT LVADs will be implanted and for longer durations, and more patients will face EOL issues. A multidisciplinary team approach with protocols involving DT patients and their families in EOL decision making allows for continuity of care and ensures dignity and comfort at EOL.
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Affiliation(s)
- Sally Brush
- Utah Artificial Heart Program, and Intermountain Medical Center and Intermountain Healthcare, Salt Lake City, Utah 84107, USA
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Swetz KM, Freeman MR, Mueller PS, Park SJ. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010; 29:1081. [DOI: 10.1016/j.healun.2010.04.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 04/29/2010] [Indexed: 11/26/2022] Open
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Mueller PS, Swetz KM, Freeman MR, Carter KA, Crowley ME, Severson CJA, Park SJ, Sulmasy DP. Ethical analysis of withdrawing ventricular assist device support. Mayo Clin Proc 2010; 85:791-7. [PMID: 20584919 PMCID: PMC2931614 DOI: 10.4065/mcp.2010.0113] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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.
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Affiliation(s)
- Paul S Mueller
- Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Hoping for a miracle: supporting patients in transplantation and cardiac assist programs. Curr Opin Support Palliat Care 2009; 2:252-5. [PMID: 19069309 DOI: 10.1097/spc.0b013e32831a7280] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Palliative medicine is often viewed as a medical specialty reserved for end of life care. This review focuses on the role that palliative care can play in transplant and cardiac assist device programs, along the continuum of a patient's disease course. RECENT FINDINGS In general, transplant and cardiac assist programs do not incorporate palliative medicine during the treatment course, but rather reserve it for when the patient is approaching death and is no longer a candidate for transplant or device therapy. There is a new shift, however, to viewing the practice of aggressive medicine and palliative medicine as 'shared care' so as to optimize the patient's quality of life throughout his or her illness. CONCLUSION Transplant and cardiac assist device programs should not exclude the practice of palliative care in their daily work. Palliative care is not 'giving up' rather it is optimizing the quality of a patient's life irrespective of the level of disease severity and prognosis.
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Rizzieri AG, Verheijde JL, Rady MY, McGregor JL. Ethical challenges with the left ventricular assist device as a destination therapy. Philos Ethics Humanit Med 2008; 3:20. [PMID: 18694496 PMCID: PMC2527574 DOI: 10.1186/1747-5341-3-20] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 08/11/2008] [Indexed: 05/26/2023] Open
Abstract
The left ventricular assist device was originally designed to be surgically implanted as a bridge to transplantation for patients with chronic end-stage heart failure. On the basis of the REMATCH trial, the US Food and Drug Administration and the US Centers for Medicare & Medicaid Services approved permanent implantation of the left ventricular assist device as a destination therapy in Medicare beneficiaries who are not candidates for heart transplantation. The use of the left ventricular assist device as a destination therapy raises certain ethical challenges. Left ventricular assist devices can prolong the survival of average recipients compared with optimal medical management of chronic end-stage heart failure. However, the overall quality of life can be adversely affected in some recipients because of serious infections, neurologic complications, and device malfunction. Left ventricular assist devices alter end-of-life trajectories. The caregivers of recipients may experience significant burden (e.g., poor physical health, depression, anxiety, and posttraumatic stress disorder) from destination therapy with left ventricular assist devices. There are also social and financial ramifications for recipients and their families. We advocate early utilization of a palliative care approach and outline prerequisite conditions so that consenting for the use of a left ventricular assist device as a destination therapy is a well informed process. These conditions include: (1) direct participation of a multidisciplinary care team, including palliative care specialists, (2) a concise plan of care for anticipated device-related complications, (3) careful surveillance and counseling for caregiver burden, (4) advance-care planning for anticipated end-of-life trajectories and timing of device deactivation, and (5) a plan to address the long-term financial burden on patients, families, and caregivers.Short-term mechanical circulatory devices (e.g. percutaneous cardiopulmonary bypass, percutaneous ventricular assist devices, etc.) can be initiated in emergency situations as a bridge to permanent implantation of ventricular assist devices in chronic end-stage heart failure. In the absence of first-person (patient) consent, presumed consent or surrogate consent should be used cautiously for the initiation of short-term mechanical circulatory devices in emergency situations as a bridge to permanent implantation of left ventricular assist devices. Future clinical studies of destination therapy with left ventricular assist devices should include measures of recipients' quality of end-of-life care and caregivers' burden.
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Affiliation(s)
- Aaron G Rizzieri
- Department of Philosophy, Arizona State University, 300 East University Drive, Tempe, Arizona, 85287, USA
| | - Joseph L Verheijde
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, Arizona, 85054, USA
- Bioethics, Policy, and Law Program, Arizona State University, 300 East University Drive, Tempe, Arizona, 85287, USA
| | - Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, Arizona, 85054, USA
| | - Joan L McGregor
- Bioethics, Policy, and Law Program, Arizona State University, 300 East University Drive, Tempe, Arizona, 85287, USA
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