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CardioBrief: Some Doctors Reluctant To Deactivate LVADs
LVAD deactivation is not euthanasia or physician-assisted suicide
by Larry Husten, CardioBrief October 05, 2017
Left ventricular assist devices (LVADs) are used increasingly as destination therapy instead of as a temporary bridge until a donor heart becomes available for transplantation. Now patients, their families, and their caregivers are forced to confront the extremely difficult question of when and how to turn off these devices at the end of life.
"In the United States, the ethical and legal principles of LVAD deactivation are well-established," Colleen K. McIlvennan (University of Colorado) and colleagues wrote in the Journal of Cardiac Failure. "An LVAD is considered a life support treatment, not a replacement treatment. Therefore, patients who have decision-making capacity or their surrogates may request deactivation of the life support treatment -- in this case, an LVAD -- when it is considered no longer effective or is believed to be more burdensome than beneficial."
But the new paper offers evidence that some clinicians view "the act of LVAD deactivation as euthanasia or physician-assisted suicide." In cases where clinicians don't agree with the decision to deactivate the LVAD the authors wrote that "it is the clinician's professional responsibility to transfer care to someone who can carry out the patient's wishes."
The paper is based on a survey administered to cardiologists and hospice and palliative medicine clinicians (HPMs), and the findings raise important questions about how and whether medical professionals are prepared to deal with a fundamentally disruptive technology like the LVAD. The survey also suggested that cardiologists' and HPMs' opinions diverge in key areas.
However, the specific results should not by any means be taken as definitive, since the study has important limitations: in particular, only 440 responded out of 7,168 invited to participate. The results then should not be considered representative of either group, but suggest areas of concern requiring further research.
Among the key findings:
42% of cardiologists and 57% of HPMs had experience with a patient at the end of life who had requested LVAD deactivation
26% of cardiologists and 92% of HPMs "felt comfortable ordering the LVAD deactivation"
26% of cardiologists and 59% of clinicians said they would be "comfortable" personally turning off the device
17% of cardiologists and 3% of HPMs said they had refused a request to turn off an LVAD
74% of cardiologists and 42% of HPMs thought a physician should be present at the time of device inactivation
60% of cardiologists and 2% of HPMs believe a patient must be "imminently dying" for inactivation to be considered
57% of cardiologists and 88% of HPMs thought that requests to deactivate the device should be honored in patients who were not near death
A report last year from the same group found that LVAD patients and their caregivers suffer from an extraordinary amount of confusion and uncertainty near the end of life. Together, the two papers highlight that solving the difficult technical and medical issues associated with a new technology like the LVAD is only the beginning, since these technologies may result in unprecedented challenges. It is relatively easy to imagine the benefits created by a life-saving technology like an LVAD; it is far more difficult to imagine the unintended consequences of such a technology, such as the ethical issues involved in turning a life-sustaining device off.