Ethical challenges with the left ventricular assist device as a destination therapy |
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Authors: | Aaron G Rizzieri Joseph L Verheijde Mohamed Y Rady Joan L McGregor |
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Institution: | (1) Department of Philosophy, Arizona State University, 300 East University Drive, Tempe, Arizona 85287, USA;(2) Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, Arizona 85054, USA;(3) Bioethics, Policy, and Law Program, Arizona State University, 300 East University Drive, Tempe, Arizona 85287, USA;(4) Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, Arizona 85054, USA |
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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. |
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