Ethical challenges with the left ventricular assist device as a destination therapy

Aaron G. Rizzieri, Joseph L. Verheijde, Mohamed Y. Rady, Joan McGregor

Research output: Contribution to journalArticle

81 Citations (Scopus)

Abstract

The left ventricular assist device was originally designed to be surgically implanted as a bridge to transplantation for patients with chronic end-stage heart failure. On the basis of the REMATCH trial, the US Food and Drug Administration and the US Centers for Medicare & Medicaid Services approved permanent implantation of the left ventricular assist device as a destination therapy in Medicare beneficiaries who are not candidates for heart transplantation. The use of the left ventricular assist device as a destination therapy raises certain ethical challenges. Left ventricular assist devices can prolong the survival of average recipients compared with optimal medical management of chronic end-stage heart failure. However, the overall quality of life can be adversely affected in some recipients because of serious infections, neurologic complications, and device malfunction. Left ventricular assist devices alter end-of-life trajectories. The caregivers of recipients may experience significant burden (e.g., poor physical health, depression, anxiety, and posttraumatic stress disorder) from destination therapy with left ventricular assist devices. There are also social and financial ramifications for recipients and their families. We advocate early utilization of a palliative care approach and outline prerequisite conditions so that consenting for the use of a left ventricular assist device as a destination therapy is a well informed process. These conditions include: (1) direct participation of a multidisciplinary care team, including palliative care specialists, (2) a concise plan of care for anticipated device-related complications, (3) careful surveillance and counseling for caregiver burden, (4) advance-care planning for anticipated end-of-life trajectories and timing of device deactivation, and (5) a plan to address the long-term financial burden on patients, families, and caregivers. Short-term mechanical circulatory devices (e.g. percutaneous cardiopulmonary bypass, percutaneous ventricular assist devices, etc.) can be initiated in emergency situations as a bridge to permanent implantation of ventricular assist devices in chronic end-stage heart failure. In the absence of first-person (patient) consent, presumed consent or surrogate consent should be used cautiously for the initiation of short-term mechanical circulatory devices in emergency situations as a bridge to permanent implantation of left ventricular assist devices. Future clinical studies of destination therapy with left ventricular assist devices should include measures of recipients' quality of end-of-life care and caregivers' burden.

Original languageEnglish (US)
Article number20
JournalPhilosophy, Ethics, and Humanities in Medicine
Volume3
Issue number1
DOIs
StatePublished - Aug 11 2008

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Heart-Assist Devices
Caregivers
Equipment and Supplies
Therapeutics
Heart Failure
Medicare
Palliative Care
Presumed Consent
Emergencies
Therapy
Advance Care Planning
Quality of Life
Terminal Care
Medicaid
United States Food and Drug Administration
Heart Transplantation
Post-Traumatic Stress Disorders
Cardiopulmonary Bypass
Nervous System
Counseling

ASJC Scopus subject areas

  • Health Policy
  • History and Philosophy of Science
  • Issues, ethics and legal aspects
  • Medicine(all)

Cite this

Ethical challenges with the left ventricular assist device as a destination therapy. / Rizzieri, Aaron G.; Verheijde, Joseph L.; Rady, Mohamed Y.; McGregor, Joan.

In: Philosophy, Ethics, and Humanities in Medicine, Vol. 3, No. 1, 20, 11.08.2008.

Research output: Contribution to journalArticle

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