1
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Kelemen A, Groninger H, Yearwood EL, French C, Bither C, Rao A, Anderson KM. The experiences among bereaved family members after a left ventricular assist device (LVAD) deactivation. Heart Lung 2024; 66:117-122. [PMID: 38604055 DOI: 10.1016/j.hrtlng.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/06/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The use of left ventricular assist devices (LVADs) is increasing with an estimated 2500 devices implanted each year. When burdens of the LVAD outweigh benefits, most individuals with LVADs will undergo deactivation in the hospital setting. While the decision to deactivate an LVAD is considered an ethical practice, little is known about the experience and needs of bereaved family members. OBJECTIVE To investigate the experiences of bereaved family members of patients who died following LVAD deactivation. METHODS In this qualitative study, 11 family members of patients who underwent LVAD deactivation were interviewed. The semi-structured interviews were conducted until data saturation was reached and relevant themes emerged. RESULTS This qualitative study was conducted to understand the experience of family members before, during and after the patient underwent LVAD deactivation, including their perceptions of engagement with the healthcare team. Analysis revealed six overarching themes from the experience, including 1) hope for survival, 2) communication, 3) spirituality and faith, 4) absence of physical suffering, 5) positive relationships with staff, 6) post-death care needs. CONCLUSION Bereaved family members of patients undergoing LVAD deactivation have unique lived experiences and concerns. This study highlights the importance of effective communication not only near end-of-life but throughout the LVAD experience. While the positive relationships with staff and the absence of physical suffering were strengths identified by bereaved caregivers, there is an opportunity for improvement, particularly during the decision-making and post-death periods.
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Affiliation(s)
| | - Hunter Groninger
- Section of Palliative Care, Department of Medicine, MedStar Washington Hospital Center, MedStar Palliative Care, Georgetown University, 110 Irving Street NW, Room 2A68, Washington, DC 20010, USA
| | - Edilma L Yearwood
- Georgetown University School of Nursing, 3700 Reservoir Rd, NW., Washington, DC 20057, USA
| | | | - Cindy Bither
- Adv HF Program, Suite 2A-7, Medstar Washington Hospital Center, Washington, DC 20010, USA
| | - Anirudh Rao
- Section of Palliative Care, MedStar Washington Hospital Center, Georgetown University School of Medicine, USA
| | - Kelley M Anderson
- PhD in Nursing Program, Georgetown University, School of Nursing, 3700 Reservoir Road, 245 St. Mary's Hall, Washington, DC 20057, USA
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2
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Zaidi D, Kirkpatrick JN, Fedson SE, Hull SC. Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework. JACC. HEART FAILURE 2023; 11:1481-1490. [PMID: 37768252 DOI: 10.1016/j.jchf.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/06/2023] [Accepted: 08/08/2023] [Indexed: 09/29/2023]
Abstract
Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.
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Affiliation(s)
- Danish Zaidi
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Savitri E Fedson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA; Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA.
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3
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Hill L, Baruah R, Beattie JM, Bistola V, Castiello T, Celutkienė J, Di Stolfo G, Geller TP, Lambrinou E, Mindham R, McIlfatrick S, Strömberg A, Jaarsma T. Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care. Eur J Heart Fail 2023; 25:1481-1492. [PMID: 37477052 DOI: 10.1002/ejhf.2973] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/29/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.
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Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
- College of Nursing and Midwifery, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Resham Baruah
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - James M Beattie
- Cicely Saunders Institute, King's College London, London, UK
| | - Vasiliki Bistola
- National and Kapodistrian University of Athens, Department of Cardiology, Heart Failure Unit, Attikon University Hospital, Athens, Greece
| | - Teresa Castiello
- Department of Cardiovascular Imaging, King's College London, Croydon Health Service London, London, UK
| | - Jelena Celutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Giuseppe Di Stolfo
- Cardiovascular Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Tal Prager Geller
- Palliative care centre DOROT medical centre Netanya, Netanya, Israel
| | | | - Richard Mindham
- United Kingdom European Society of Cardiology Patient Forum, Sophia Antipolis, France
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, Ulster University, Belfast, UK
| | - Anna Strömberg
- Department of Health, Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
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4
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Garcia MAG, Grouls A. End-of-Life Issues in Patients With Left Ventricular Assist Devices. Tex Heart Inst J 2023; 50:e238160. [PMID: 37440292 PMCID: PMC10660132 DOI: 10.14503/thij-23-8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Mary Acelle G Garcia
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Astrid Grouls
- Department of Medicine, Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas
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5
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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6
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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7
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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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8
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Johnson MH, Bass C, Schroeder SE. The Fountain of Youth Will Not Last Forever: End of Life in Patients Receiving Mechanical Circulatory Support. AACN Adv Crit Care 2021; 32:452-460. [PMID: 34879128 DOI: 10.4037/aacnacc2021501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Health care providers face a unique set of decision-making, assessment, and equipment challenges at the end of life of patients supported with a left ventricular assist device. The aim for this article is to assist the multidisciplinary team in caring for patients with a left ventricular assist device in all phases of end-of-life care. This review includes common causes of death for patients with a left ventricular assist device, assessment at end of life, physiological and palliative care considerations, withdrawal of left ventricular assist device support, and equipment considerations.
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Affiliation(s)
- Mary H Johnson
- Mary H. Johnson is VAD Educator, The Christ Hospital, 2123 Auburn Avenue, Suite 115, Cincinnati, OH
| | - Colleen Bass
- Colleen Bass is Palliative Care Nurse Practitioner, The Christ Hospital, Cincinnati, Ohio
| | - Sarah E Schroeder
- Sarah E. Schroeder is VAD Nurse Practitioner and Program Manager, Bryan Heart, Lincoln, Nebraska
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9
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Hayes EA, Nandi D. Is there a future for the use of left ventricular assist devices in Duchenne muscular dystrophy? Pediatr Pulmonol 2021; 56:753-759. [PMID: 33245216 DOI: 10.1002/ppul.25181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/05/2020] [Accepted: 11/12/2020] [Indexed: 01/14/2023]
Abstract
Duchenne muscular dystrophy (DMD) is the most common form of childhood muscular dystrophy resulting in progressive muscle wasting and weakness. With advancements in respiratory care and the use of glucocorticoids, cardiomyopathy has surpassed respiratory compromise as the leading cause of morbidity and mortality in this patient population. As muscular dystrophy remains a relative contraindication to heart transplantation, end-stage heart failure management represents a major therapeutic challenge. Long-term left ventricular assist device (LVAD) therapy has emerged as a promising management strategy to improve the survival and quality of life in DMD cardiomyopathy. Preoperative planning, optimal patient selection, aggressive postoperative rehabilitation, and continued discussion of goals of care are critical considerations for the appropriate use of LVAD in DMD patients with cardiomyopathy.
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Affiliation(s)
- Emily A Hayes
- Division of Cardiology, The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Deipanjan Nandi
- Division of Cardiology, The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
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10
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Nakagawa S, Takayama H, Takeda K, Topkara VK, Yuill L, Zampetti S, McLaughlin K, Yuzefpolskaya M, Colombo PC, Naka Y, Uriel N, Blinderman CD. Association Between "Unacceptable Condition" Expressed in Palliative Care Consultation Before Left Ventricular Assist Device Implantation and Care Received at the End of Life. J Pain Symptom Manage 2020; 60:976-983.e1. [PMID: 32464259 DOI: 10.1016/j.jpainsymman.2020.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown. OBJECTIVES To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life. METHODS Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups. RESULTS Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life. CONCLUSION Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.
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Affiliation(s)
- Shunichi Nakagawa
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA.
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Lauren Yuill
- Department of Care Coordination and Social Work, Adult Palliative Care Service, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Suzanne Zampetti
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA
| | - Katherine McLaughlin
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig D Blinderman
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA
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11
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Pak ES, Jones CA, Mather PJ. Ethical Challenges in Care of Patients on Mechanical Circulatory Support at End-of-Life. Curr Heart Fail Rep 2020; 17:153-160. [DOI: 10.1007/s11897-020-00460-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Roggi S, Picozzi M. Is Left Ventricular Assist Device Deactivation Ethically Acceptable? A Study on the Euthanasia Debate. HEC Forum 2020; 33:325-343. [PMID: 32253568 PMCID: PMC8585806 DOI: 10.1007/s10730-020-09408-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the last decades, new technologies have improved the survival of patients affected by chronic illnesses. Among them, left ventricular assist device (LVAD) has represented a viable solution for patients with advanced heart failure (HF). Even though the LVAD prolongs life expectancy, patients’ vulnerability generally increases during follow up and patients’ request for the device withdrawal might occur. Such a request raises some ethical concerns in that it directly hastens the patient’s death. Hence, in order to assess the ethical acceptability of LVAD withdrawal, we analyse and examine an ethical argument, widely adopted in the literature, that we call the “descriptive approach”, which consists in giving a definition of life-sustaining treatment to evaluate the ethical acceptability of treatment withdrawal. Focusing attention on LVAD, we show criticisms of this perspective. Finally, we assess every patient’s request of LVAD withdrawal through a prescriptive approach, which finds its roots in the criterion of proportionality.
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Affiliation(s)
- Sara Roggi
- Center for Clinical Ethics (CREC), Doctoral School in Clinical and Experimental Medicine and Medical Humanities, Biotechnologies and Life Sciences Department, Insubria University, Via Ottorino Rossi 9, 21100, Varese, Italy. .,Centre de Recherche sur le Liens Sociaux (CERLIS), Doctoral School 180 in Human et Social Sciences: Cultures, Individuals and Societies, Paris Descartes University, Galerie Gerson, 1st Floor, 54, Rue Saint Jacques, 75005, Paris, France.
| | - Mario Picozzi
- Center for Clinical Ethics, Biotechnologies and Life Sciences Department, Insubria University, Via Ottorino Rossi 9, 21100, Varese, Italy
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13
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Slavin SD, Allen LA, McIlvennan CK, Desai AS, Schaefer KG, Warraich HJ. Left Ventricular Assist Device Withdrawal: Ethical, Psychological, and Logistical Challenges. J Palliat Med 2020; 23:456-458. [DOI: 10.1089/jpm.2019.0622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Samuel D. Slavin
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Larry A. Allen
- Department of Medicine, University of Colorado, Aurora, Colorado
| | | | - Akshay S. Desai
- Division of Cardiovascular Medicine, Department of Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kristen G. Schaefer
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Haider J. Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiology Section, Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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14
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Nakagawa S, Ando M, Takayama H, Takeda K, Garan AR, Yuill L, Rosen A, Topkara VK, Yuzefpolskaya M, Colombo PC, Naka Y, Blinderman CD. Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution. J Palliat Med 2020; 23:368-374. [DOI: 10.1089/jpm.2019.0322] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Shunichi Nakagawa
- Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Masahiko Ando
- Division of Cardiothoracic Surgery, Department of Surgery, Tokyo University, Tokyo, Japan
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Arthur R. Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Lauren Yuill
- Adult Palliative Care, Department of Care Coordination and Social Work, NewYork Presbyterian Hospital, New York, New York
| | - Amanda Rosen
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C. Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Craig D. Blinderman
- Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York
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15
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Chernyak Y, Teh L, Henderson DR, Patel A. Practice Issues for Evaluation and Management of the Suicidal Left Ventricular Assist Device Patient. Prog Transplant 2019; 30:63-66. [PMID: 31876252 DOI: 10.1177/1526924819893300] [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] [Indexed: 11/17/2022]
Abstract
There is a high prevalence of depression among left ventricular assist device patients, who present with an increased risk of suicidality given access to means via the device either with nonadherence or disconnection. Suicidality via device nonadherence/disconnection is an underresearched clinical issue, as paradoxically this life-saving procedure can also provide a method of lethal means to patients with significant mental health concerns. A case study is used to highlight the course of an attempted suicide by ventricular assistive device nonadherence. Clinical implications and recommendations for practice include a thorough psychological evaluation presurgery, monitoring quality of life and coping styles before and after placement, psychological testing, outlining specific suicide protocols, psychiatric care considerations for patients with highly specialized medical devices, and related ethical concerns.
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Affiliation(s)
- Yelena Chernyak
- Department of Psychiatry, Indiana University School of Medicine, IU Health Neurosciences Center, Indianapolis, IN, USA
| | - Lisa Teh
- Department of Psychiatry, Indiana University School of Medicine, IU Health Neurosciences Center, Indianapolis, IN, USA
| | - Danielle R Henderson
- Department of Psychiatry, Indiana University School of Medicine, IU Health Neurosciences Center, Indianapolis, IN, USA
| | - Anahli Patel
- Department of Psychiatry, Indiana University School of Medicine, IU Health Neurosciences Center, Indianapolis, IN, USA
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16
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Entwistle JWC, Fenton KN. Rethinking the ethics of ventricular assist device withdrawal. J Thorac Cardiovasc Surg 2019; 159:1328-1332. [PMID: 31810648 DOI: 10.1016/j.jtcvs.2019.06.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 06/17/2019] [Accepted: 06/23/2019] [Indexed: 11/30/2022]
Affiliation(s)
- John W C Entwistle
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa.
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17
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Gamble JL, Gamble NK, Pruski M. To die, to sleep, perchance to dream? A response to DeMichelis, Shaul and Rapoport. JOURNAL OF MEDICAL ETHICS 2019; 45:832-834. [PMID: 31320406 DOI: 10.1136/medethics-2019-105393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/02/2019] [Accepted: 05/07/2019] [Indexed: 06/10/2023]
Abstract
In developing their policy on paediatric medical assistance in dying (MAID), DeMichelis, Shaul and Rapoport decide to treat euthanasia and physician-assisted suicide as ethically and practically equivalent to other end-of-life interventions, particularly palliative sedation and withdrawal of care (WOC). We highlight several flaws in the authors' reasoning. Their argument depends on too cursory a dismissal of intention, which remains fundamental to medical ethics and law. Furthermore, they have not fairly presented the ethical analyses justifying other end-of-life decisions, analyses and decisions that were generally accepted long before MAID was legal or considered ethical. Forgetting or misunderstanding the analyses would naturally lead one to think MAID and other end-of-life decisions are morally equivalent. Yet as we recall these well-developed analyses, it becomes clear that approving of some forms of sedation and WOC does not commit one to MAID. Paediatric patients and their families can rationally and coherently reject MAID while choosing palliative care and WOC. Finally, the authors do not substantiate their claim that MAID is like palliative care in that it alleviates suffering. It is thus unreasonable to use this supposition as a warrant for their proposed policy.
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Affiliation(s)
- Joel L Gamble
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nathan K Gamble
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michal Pruski
- Manchester Metropolitan University, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
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Joong A, Derrington SF, Patel A, Thrush PT, Allen KY, Marino BS. Providing Compassionate End of Life Care in the Setting of Mechanical Circulatory Support. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00206-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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DeFilippis EM, Nakagawa S, Maurer MS, Topkara VK. Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. J Am Geriatr Soc 2019; 67:2410-2419. [DOI: 10.1111/jgs.16105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Ersilia M. DeFilippis
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Shunichi Nakagawa
- Adult Palliative Care, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
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Kaufman BD, Hollander SA, Zhang Y, Chen S, Bernstein D, Rosenthal DN, Almond CS, Murray JM, Burgart AM, Cohen HJ, Kirkpatrick JN, Blume ED. Compassionate deactivation of ventricular assist devices in children: A survey of pediatric ventricular assist device clinicians' perspectives and practices. Pediatr Transplant 2019; 23:e13359. [PMID: 30734422 DOI: 10.1111/petr.13359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study's objective was to investigate compassionate ventricular assist device deactivation (VADdeact) in children from the perspective of the pediatric heart failure provider. BACKGROUND Pediatric VAD use is a standard therapy for advanced heart failure. Serious adverse events may affect relative benefit of continued support, leading to consideration of VADdeact. Perspectives and practices regarding VADdeact have been studied in adults but not in children. METHODS A web-based anonymous survey of clinicians for pediatric VAD patients (<18 years) was sent to list-serves for the ISHLT Pediatric Council, the International Consortium of Circulatory Assist Clinicians Pediatric Taskforce, and the Pediatric Cardiac Intensivist Society. RESULTS A total of 106 respondents met inclusion criteria of caring for pediatric VAD patients. Annual VAD volume per clinician ranged from <4 (33%) to >9 (20%). Seventy percent of respondents had performed VADdeact of a child. Response varied to VADdeact requests by parent or patient and was influenced by professional degree and region of practice. Except for the scenario of intractable suffering, no consensus on VADdeact appropriateness was reported. Age of child thought capable of making informed requests for VADdeact varied by subspecialty. The majority of respondents (62%) do not feel fully informed of relevant legal issues; 84% reported that professional society supported guidelines for VADdeact in children had utility. CONCLUSION There is limited consensus regarding indications for VADdeact in children reported by pediatric VAD provider survey respondents. Knowledge gaps related to legal issues are evident; therefore, professional guidelines and educational resources related to pediatric VADdeact are needed.
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Affiliation(s)
- Beth D Kaufman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yulin Zhang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sharon Chen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David N Rosenthal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Christopher S Almond
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jenna M Murray
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Burgart
- Anesthesiology, Perioperative and Pain Medicine, Stanford Center for Biomedical Ethics, Stanford University, Palo Alto, California
| | - Harvey J Cohen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - James N Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington Medical Center, Seattle, Washington
| | - Elizabeth D Blume
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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Char D, Hollander SA. The Decision to Withdraw in Children With Ventricular Assist Devices. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:61-62. [PMID: 31543046 DOI: 10.1080/15265161.2018.1563655] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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22
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Warraich HJ, Maurer MS, Patel CB, Mentz RJ, Swetz KM. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Left Ventricular Assist Devices. J Palliat Med 2019; 22:437-441. [PMID: 30794023 DOI: 10.1089/jpm.2019.0044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Advanced heart failure (HF) is a common condition that leads to significant suffering for patients and their families. Left ventricular assist devices (LVADs) can improve both the quantity and quality of life for those suffering with advanced HF. Palliative care clinicians are being asked with increasing frequency to assist HF teams to manage patients with LVADs in the preimplantation, post-operative, and end-of-life settings, although not all palliative care providers feel comfortable with this technology. Written by specialists in HF, geriatric cardiology, and palliative care, this article seeks to improve palliative care providers' knowledge of LVADs and will prepare palliative care teams to counsel and support LVAD patients and their families from pre-implantation to the end of life.
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Affiliation(s)
- Haider J Warraich
- 1 Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina
| | - Mathew S Maurer
- 2 Division of Cardiology, Department of Medicine, Center for Advanced Cardiac Care, Columbia University Medical Center, New York, New York
| | - Chetan B Patel
- 1 Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina
| | - Robert J Mentz
- 1 Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina
| | - Keith M Swetz
- 3 Division of Gerontology, Geriatrics and Pallative Care, University of Alabama-Birmingham and Section of Pallative Care, Birmingham VA Medical Center, Birmingham, Alabama
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Nakagawa S, Garan AR, Takayama H, Takeda K, Topkara VK, Yuzefpolskaya M, Lin SX, Colombo PC, Naka Y, Blinderman CD. End of Life with Left Ventricular Assist Device in Both Bridge to Transplant and Destination Therapy. J Palliat Med 2018; 21:1284-1289. [DOI: 10.1089/jpm.2018.0112] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Shunichi Nakagawa
- Adult Palliative Care Service, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Arthur R. Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Susan X. Lin
- Center for Family and Community Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C. Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Craig D. Blinderman
- Adult Palliative Care Service, Department of Medicine, Columbia University Medical Center, New York, New York
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Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies. Pediatr Crit Care Med 2018; 19:S10-S18. [PMID: 30080802 DOI: 10.1097/pcc.0000000000001488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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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Klinedinst R, Kornfield ZN, Hadler RA. Palliative Care for Patients With Advanced Heart Disease. J Cardiothorac Vasc Anesth 2018; 33:833-843. [PMID: 29793760 DOI: 10.1053/j.jvca.2018.04.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Indexed: 11/11/2022]
Abstract
Over the past 2 decades, the discipline of palliative care has evolved and expanded such that it is now the standard of care for a variety of acute and chronic processes. Although there are recommendations encouraging incorporation of palliative care into the routine management of patients with chronic cardiac processes, such as congestive heart failure, implementation has been challenging, and nowhere more so than in the cardiac surgical population. However, as the boundaries of surgical care have expanded to include progressively more complex cases, increasing attention has been given to the integration of palliative care into their management. In this review article, the authors describe the existing evidence for palliative care team involvement in patients with non-operative and surgical cardiac diseases and examine future directions for growth in this field.
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Affiliation(s)
- Rachel Klinedinst
- Division of Palliative Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Z Noah Kornfield
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel A Hadler
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
PURPOSE OF REVIEW This review illustrates the dynamic role of palliative care in heart failure management and encapsulates the commonly utilized pharmacologic and non-pharmacologic therapeutic strategies for symptom palliation in heart failure. In addition, we provide our experience regarding patient care issues common to the domain of heart failure and palliative medicine which are commonly encountered by heart failure teams. RECENT FINDINGS Addition of palliative care to conventional heart failure management plan results in improvement in quality of life, anxiety, depression, and spiritual well-being among patients. Palliative care should not be confused with hospice care. Palliative care teams should be involved early in the care of heart failure patients with the aims of improving symptom palliation, discussing goals of care and improving quality of life without compromising utilization of evidence-based heart failure therapies. A consensus on the appropriate timing of involvement and evidence for many symptom palliation therapies is still emerging.
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Abstract
ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.
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Affiliation(s)
- Roxanne Kirsch
- Department of Critical Care, The Hospital for Sick Children, Toronto, Canada; Department of Bioethics, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada.
| | - David Munson
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
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Foëx BA. He was brought in blue… with an LVAD. Arch Emerg Med 2017; 34:850-851. [DOI: 10.1136/emermed-2017-207298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 11/04/2022]
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30
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Wordingham SE, McIlvennan CK, Fendler TJ, Behnken AL, Dunlay SM, Kirkpatrick JN, Swetz KM. Palliative Care Clinicians Caring for Patients Before and After Continuous Flow-Left Ventricular Assist Device. J Pain Symptom Manage 2017; 54:601-608. [PMID: 28711755 DOI: 10.1016/j.jpainsymman.2017.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 04/17/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
Left ventricular assist devices (LVADs) are an available treatment option for carefully selected patients with advanced heart failure. Initially developed as a bridge to transplantation, LVADs are now also offered to patients ineligible for transplantation as destination therapy (DT). Individuals with a DT-LVAD will live the remainder of their lives with the device in place. Although survival and quality of life improve with LVADs compared with medical therapy, complications persist including bleeding, infection, and stroke. There has been increased emphasis on involving palliative care (PC) specialists in LVAD programs, specifically the DT-LVAD population, from the pre-implantation process through the end of life. Palliative care specialists are well poised to provide education, guidance, and support to patients, families, and clinicians throughout the LVAD journey. This article addresses the complexities of the LVAD population, describes key challenges faced by PC specialists, and discusses opportunities for building collaboration between PC specialists and LVAD teams.
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Affiliation(s)
| | | | | | | | | | | | - Keith M Swetz
- University of Alabama-Birmingham, Birmingham, Alabama, USA; Birmingham VA Medical Center, Birmingham, Alabama, USA.
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31
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Makdisi T, Makdisi G. Ethical challenges and terminal deactivation of left ventricular assist device. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:331. [PMID: 28861428 DOI: 10.21037/atm.2017.04.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tony Makdisi
- Palliative Care Division, University of Massachusetts Medical School, Berkshire Medical Center, Pittsfield, MA, USA
| | - George Makdisi
- Division of Cardiothoracic Surgery, University of South Florida, Tampa General Hospital, Tampa, FL, USA
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Verdoorn BP, Luckhardt AJ, Wordingham SE, Dunlay SM, Swetz KM. Palliative Medicine and Preparedness Planning for Patients Receiving Left Ventricular Assist Device as Destination Therapy-Challenges to Measuring Impact and Change in Institutional Culture. J Pain Symptom Manage 2017; 54:231-236. [PMID: 28093312 PMCID: PMC5511781 DOI: 10.1016/j.jpainsymman.2016.10.372] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/20/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023]
Abstract
CONTEXT Although left ventricular assist devices as destination therapy (DT-LVAD) can improve survival, quality of life, and functional capacity in well-selected patients with advanced heart failure, there remain unique challenges to providing quality end-of-life care in this population. Palliative care involvement is universally recommended, but how to best operationalize this care and measure success is unknown. OBJECTIVES To characterize the process of preparedness planning (PP) for patients receiving DT-LVAD at our institution and better understand opportunities for quality improvement or procedural transferability. METHODS Retrospective review of 107 consecutive patients undergoing DT-LVAD implantation at a single institution between 2009 and 2013. Information regarding demographics, advance care planning, and mortality was abstracted from the medical record and analyzed. Findings were compared with a historical cohort who received DT-LVAD implantation at the same institution before the development of PP (2003-2009). RESULTS Mean age of patients receiving DT-LVAD was 64.3 years (SD ± 10.7). At last follow-up, 46 patients (43%) had died. Mean post-DT-LVAD survival in this group was 1.1 years (SD ± 1.2). Eighty-nine percent of patient had palliative care consultation before implantation, and 70% completed PP. Although 66% of patients completed an advance directive (AD) preimplantation, only two ADs (2.8%) specifically mentioned DT-LVAD and none addressed core elements of PP. AD completion rates improved from 47% before our policy on PP (P = 0.012). CONCLUSION A disconnect was evident between the rigor of PP discussions and the content of ADs in the medical record. We urge that future efforts focus on narrowing this gap.
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Affiliation(s)
| | - Angela J Luckhardt
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shannon M Dunlay
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
| | - Keith M Swetz
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Dunlay SM, Strand JJ, Wordingham SE, Stulak JM, Luckhardt AJ, Swetz KM. Dying With a Left Ventricular Assist Device as Destination Therapy. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003096. [PMID: 27758809 DOI: 10.1161/circheartfailure.116.003096] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 09/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the ability of left ventricular assist device as destination therapy (DT-LVAD) to prolong survival for many patients with advanced heart failure, little is known about the eventual end-of-life care that patients with DT-LVAD receive. METHODS AND RESULTS All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota, from January 1, 2007, to September 30, 2014, who subsequently died before July 1, 2015, were included. Information about end-of-life care was obtained from documentation in the electronic medical record. Of 89 patients who died with a DT-LVAD, the median (25th-75th percentile) time from left ventricular assist device implantation to death was 14 (4-31) months. The most common causes of death were multiorgan failure (26%), hemorrhagic stroke (24%), and progressive heart failure (21%). Nearly half (46%) of the patients saw palliative care within 1 month before death; however, only 13 (15%) patients enrolled in hospice a median 11 (range 1-315) days before death. Most patients (78%) died in the hospital, of which 88% died in the intensive care unit. In total, 49 patients had their left ventricular assist device deactivated before death, with all but 3 undergoing deactivation in the hospital. Most patients died within an hour of left ventricular assist device deactivation and all within 26 hours. CONCLUSIONS In contrast to the general heart failure population, most patients with DT-LVAD die in the hospital and few use hospice. Further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.
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Affiliation(s)
- Shannon M Dunlay
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.).
| | - Jacob J Strand
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Sara E Wordingham
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - John M Stulak
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Angela J Luckhardt
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Keith M Swetz
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
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O’Hare AM, Szarka J, McFarland LV, Vig EK, Sudore RL, Crowley S, Reinke LF, Trivedi R, Taylor JS. "Maybe They Don't Even Know That I Exist": Challenges Faced by Family Members and Friends of Patients with Advanced Kidney Disease. Clin J Am Soc Nephrol 2017; 12:930-938. [PMID: 28356337 PMCID: PMC5460720 DOI: 10.2215/cjn.12721216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/21/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes. RESULTS The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient. CONCLUSIONS Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.
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Affiliation(s)
- Ann M. O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
- Departments of Medicine and
| | - Jackie Szarka
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | | | - Elizabeth K. Vig
- Geriatrics and Extended Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Departments of Medicine and
| | - Rebecca L. Sudore
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Susan Crowley
- Veterans Affairs Westhaven and Yale University, New Haven, Connecticut
| | - Lynn F. Reinke
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Hospital and Specialty Medicine Service, and
| | - Ranak Trivedi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
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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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Rise of the Machines: In an Era of Ventricular Assist Devices, Prolonging Life or Death? J Dr Nurs Pract 2017; 10:96-107. [PMID: 32751024 DOI: 10.1891/2380-9418.10.2.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The past few decades witnessed the unprecedented "rise of the machines"; life-prolonging devices to support failing organs or as a form of organ replacement. Sophisticated machines provide us clinical milieu to intervene on sicker, dying patients, support the failing organ, prevent downward trajectory to multi-organ failure, and avert death. Hemodialysis has been in existence for several decades and has become the standard therapy for acute renal failure. Extracorporeal liver assist device replaces the detoxification function of the failing liver. Extracorporeal membrane oxygenator in cases of profound respiratory failure can replace the native lung function in the oxygenation of the venous blood and removal of carbon dioxide. The technology can also be used as a short-term heart-lung machine to keep the patient alive in the event of profound refractory cardiopulmonary collapse until the native heart and lung function returns. Ventricular assist devices (VADs) can completely replace the cardiac function in patients with end-stage heart failure and provide systemic flow. These innovative machines were developed under the assumption that they will improve survival, functional capacity, and quality of life in this cohort of patients. This case study focuses on the appropriate use of VADs as an alternative therapy for end-stage heart failure. This will explicate the ethical dilemma that concomitantly may arise with the use of these sophisticated organ replacement strategies when the goals of their placement are not met and just merely prolonging the dying process.
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McIlvennan CK, Wordingham SE, Allen LA, Matlock DD, Jones J, Dunlay SM, Swetz KM. Deactivation of Left Ventricular Assist Devices: Differing Perspectives of Cardiology and Hospice/Palliative Medicine Clinicians. J Card Fail 2016; 23:708-712. [PMID: 27932271 DOI: 10.1016/j.cardfail.2016.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Beliefs around deactivation of a left ventricular assist device (LVAD) vary substantially among clinicians, institutions, and patients. Therefore, we sought to understand perspectives regarding LVAD deactivation among cardiology and hospice/palliative medicine (HPM) clinicians. METHODS AND RESULTS We administered a 41-item survey via electronic mail to members of 3 cardiology and 1 HPM professional societies. A convergent parallel mixed-methods design was used. From October through November 2011, 7168 individuals were sent the survey and 440 responded. Three domains emerged: (1) LVAD as a life-sustaining therapy; (2) complexities of the process of LVAD deactivation; and (3) legal and ethical considerations of LVAD deactivation. Most respondents (cardiology 92%; HPM 81%; P = .15) believed that an LVAD is a life-sustaining treatment for patients with advanced heart failure; however, 60% of cardiology vs 2% of HPM clinicians believed a patient should be imminently dying to deactivate an LVAD (P < .001). Additionally, 87% of cardiology vs 100% of HPM clinicians believed the cause of death following LVAD deactivation was from underlying disease (P < .001), with 13% of cardiology clinicians considering it to be a form of euthanasia or physician-assisted suicide. CONCLUSION Cardiology and HPM clinicians have differing perspectives regarding LVAD deactivation. Bridging the gaps and engaging in dialog between these 2 specialties is a critical first step in creating a more cohesive approach to care for LVAD patients.
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Affiliation(s)
- Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado.
| | - Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Larry A Allen
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | | | - Shannon M Dunlay
- Department of Cardiovascular Diseases and Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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39
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Luo N, Rogers JG, Dodson GC, Patel CB, Galanos AN, Milano CA, O'Connor CM, Mentz RJ. Usefulness of Palliative Care to Complement the Management of Patients on Left Ventricular Assist Devices. Am J Cardiol 2016; 118:733-8. [PMID: 27474339 DOI: 10.1016/j.amjcard.2016.06.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 12/25/2022]
Abstract
Within the last decade, advancements in left ventricular assist device therapy have allowed patients with end-stage heart failure (HF) to live longer and with better quality of life. Like other life-saving interventions, however, there remains the risk of complications including infections, bleeding episodes, and stroke. The candidate for left ventricular assist device therapy faces complex challenges going forward, both physical and psychological, many of which may benefit from the application of palliative care principles by trained specialists. Despite these advantages, palliative care remains underused in many advanced HF programs. Here, we describe the benefits of palliative care, barriers to use within HF, and specific applications to the integrated care of patients on mechanical circulatory support.
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Affiliation(s)
- Nancy Luo
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Joseph G Rogers
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gwen C Dodson
- Palliative Medicine Section, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Anthony N Galanos
- Palliative Medicine Section, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher M O'Connor
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Robert J Mentz
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
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40
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Panke JT, Ruiz G, Elliott T, Pattenden DJ, DeRenzo EG, Rollins EE, Groninger H. Discontinuation of a Left Ventricular Assist Device in the Home Hospice Setting. J Pain Symptom Manage 2016; 52:313-7. [PMID: 27208865 DOI: 10.1016/j.jpainsymman.2016.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 02/02/2016] [Accepted: 02/29/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Joan T Panke
- MedStar Washington Hospital Center, Washington, DC, USA.
| | - George Ruiz
- MedStar Heart and Vascular Institute, Washington, DC, USA
| | - Tonya Elliott
- MedStar Heart and Vascular Institute, Washington, DC, USA
| | | | - Evan G DeRenzo
- Center for Ethics, MedStar Washington Hospital Center, Washington, DC, USA
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41
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Abstract
Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.
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Affiliation(s)
- Timothy J Fendler
- Division of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, 4401 Wornall Road, SLNI, CV Research, Suite 5603, Kansas City, MO 64111, USA.
| | - Keith M Swetz
- Section of Palliative Medicine, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, 12605 East 16th Avenue, 3rd Floor, Aurora, CO 80045, USA
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Hollander SA, Axelrod DM, Bernstein D, Cohen HJ, Sourkes B, Reddy S, Magnus D, Rosenthal DN, Kaufman BD. Compassionate deactivation of ventricular assist devices in pediatric patients. J Heart Lung Transplant 2016; 35:564-7. [PMID: 27197773 DOI: 10.1016/j.healun.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/14/2016] [Accepted: 03/23/2016] [Indexed: 10/22/2022] Open
Abstract
Despite greatly improved survival in pediatric patients with end-stage heart failure through the use of ventricular assist devices (VADs), heart failure ultimately remains a life-threatening disease with a significant symptom burden. With increased demand for donor organs, liberalizing the boundaries of case complexity, and the introduction of destination therapy in children, more children can be expected to die while on mechanical support. Despite this trend, guidelines on the ethical and pragmatic issues of compassionate deactivation of VAD support in children are strikingly absent. As VAD support for pediatric patients increases in frequency, the pediatric heart failure and palliative care communities must work toward establishing guidelines to clarify the complex issues surrounding compassionate deactivation. Patient, family and clinician attitudes must be ascertained and education regarding the psychological, legal and ethical issues should be provided. Furthermore, pediatric-specific planning documents for use before VAD implantation as well as deactivation checklists should be developed to assist with decision-making at critical points during the illness trajectory. Herein we review the relevant literature regarding compassionate deactivation with a specific focus on issues related to children.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA.
| | - David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Harvey J Cohen
- Department of Pediatrics (Palliative Care Services), Stanford University Medical Center, Palo Alto, California, USA
| | - Barbara Sourkes
- Department of Pediatrics (Palliative Care Services), Stanford University Medical Center, Palo Alto, California, USA
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - David Magnus
- Center for Biomedical Ethics, Stanford University, Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, USA
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University Medical Center, Palo Alto, California, 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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Rossano JW, Hoffman TM, Jefferies JL, Lorts A, Kirsch RE, Thiagarajan RR. Clinical Issues and Controversies in Heart Failure and Transplantation. World J Pediatr Congenit Heart Surg 2015; 7:63-71. [DOI: 10.1177/2150135115606622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Heart failure is a common problem among children admitted in the intensive care unit and is associated with significant morbidity and mortality. As such, the 2014 meeting of the Pediatric Cardiac Intensive Care Society included a session on Clinical Controversies in Heart Failure and Transplantation. This review contains the summaries of the podium presentations of this session and will cover some of the challenging aspects of caring for these patients including medical and mechanical support, fluid overload states, high-risk populations including those after heart transplantation, and end-of-life considerations.
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Affiliation(s)
| | | | | | - Angela Lorts
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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45
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[Ethics in intensive care and euthanasia : With respect to inactivating defibrillators at the end of life in terminally ill patients]. Med Klin Intensivmed Notfmed 2015; 112:214-221. [PMID: 26577148 DOI: 10.1007/s00063-015-0119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 09/05/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In critically ill patients, intensive care medical procedures allow diseases to be cured or controlled that were considered incurable many years ago. For patients with terminal heart failure or heart disease with other severe comorbidities (cancer, stroke), the questions whether the deactivation of defibrillators is appropriate or must be regarded as active euthanasia may arise. MATERIALS AND METHODS Notable cases from the author's hospital are analyzed. The literature on the topic euthanasia and basic literature regarding defibrillator therapy are discussed. DISCUSSION AND CONCLUSION It is undisputed that patients as part of their self-determination have the right to renounce treatment. Active euthanasia and the thereby deliberate induction of death is prohibited by law in Germany and will be prosecuted. Passive euthanasia is the omission or reduction of possibly life-prolonging treatment measures. Passive euthanasia requires the patient's consent and is legally and ethically permissible. Indirect euthanasia takes into account acceleration of death as a side effect of a medication. Unpunishable assisted suicide ("assisted suicide") is the mere assistance of self-controlled and self-determined death. Assisted suicide is fundamentally not a criminal offense in Germany. Deactivation of a defibrillator is a treatment discontinuation, which is only permitted in accordance with the wishes of the patient. It is not a question of passive or active euthanasia. Involvement of a local ethics committee and/or legal consultation is certainly useful and sometimes also allows previously unrecognized questions to be answered.
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46
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Swetz KM, Wordingham SE, Armstrong MH, Koepp KE, Ottenberg AL. Hospice and Palliative Medicine Clinician Views of Deactivation of Ventricular Assist Devices at the End of Life. J Pain Symptom Manage 2015; 50:e6-8. [PMID: 26025277 DOI: 10.1016/j.jpainsymman.2015.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/16/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Sara E Wordingham
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Katlyn E Koepp
- Division of General Internal Medicine, Department of Medicine, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, USA
| | - Abigale L Ottenberg
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, USA
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Chamsi-Pasha H, Chamsi-Pasha MA, Albar MA. Ethical challenges of deactivation of cardiac devices in advanced heart failure. Curr Heart Fail Rep 2015; 11:119-25. [PMID: 24619521 DOI: 10.1007/s11897-014-0194-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.
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Affiliation(s)
- Hassan Chamsi-Pasha
- Head of Non-Invasive Cardiology, Department of Cardiology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia,
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49
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Abstract
PURPOSE OF REVIEW Mechanical Circulatory Support (MCS) devices are 'life-sustaining devices' placed as a bridge to decision, either recovery, transplantation or a lifetime tether with the device. Cardiogenic shock may compromise patient autonomy, or the right for an individual patient to determine his own care. This review addresses an ethical dilemma in the context of complex clinical medical decision-making, during marked uncertainty for outcomes. RECENT FINDINGS The language in an advanced directive is often imprecise and may not provide clear guidance, especially for emergent decisions related to MCS devices. Despite improving outcomes, application of MCS in critical illness is associated with excessive morbidity and quality of life-limiting adverse outcomes. Several cohort experiences now exist that define deactivation of Left Ventricular Assist Devices (LVADs) in futility as now deemed as morally and ethically appropriate. In contradistinction to euthanasia, deactivation of an LVAD does not introduce new intervention or an additional surgical injury, thereby allowing the patient to die from their original disorder. SUMMARY Clinicians must maintain the principle of patient autonomy, ensure the viability of an appropriate informed consent process and facilitate surrogate judgment. An interdisciplinary team-based approach is required, and, in some cases, assisted by formal ethics consultations in vexing situations.
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50
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End-of-life care in patients with heart failure. J Card Fail 2014; 20:121-34. [PMID: 24556532 DOI: 10.1016/j.cardfail.2013.12.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 01/11/2023]
Abstract
Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.
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