This post was authored by former ACC President Alfred Bove, M.D., Ph.D., M.A.C.C. For more blogging from Dr. Bove, visit his blog on CardioSource Communities, which discusses the Heart and Diving.
A few years ago, I had the occasion to call one of our
patients who was waiting for a heart transplant with a left ventricular assist
device (LVAD). He had been on multiple
inotropic agents, but was showing progressive deterioration in his status, with
a very low serum sodium, low cardiac output, diminishing renal function and
beginning obtundation. He needed the
LVAD, and received a Heartmate-I® pulsatile LVAD as a bridge to
transplant. Immediately post-op, his
skin color was better, urine output increased, mental status improved and his
serum sodium and creatinine quickly corrected over a few days. He was
discharged to home 2 weeks later.
The occasion of my call was to answer several questions he
posed to our practice, and his wife told me that he couldn’t come to the phone
just then because he was on the roof of his house installing new shingles. I was first tempted to order him down
immediately, but thought that the reason for the LVAD was to restore a
reasonable quality of life, and that was his interpretation of a reasonable quality
of life. He finished the job
uneventfully in a few days, was non-the-worse for the effort and received his
transplant a few months later.
Working with end stage heart failure patients in a
transplant center provided the opportunity to witness the value of an LVAD when
a patient was at the extremes of heart failure and efforts to maintain
stability were failing. The patients
quickly realized the value of the device, and began to ask for its use even
when transplant was not possible. The REMATCH
trial (N Engl J Med 2001; 345:1435-1443) confirmed the concept that we could use the LVAD for
destination therapy, and we began to select patients for this therapy. These patients seemed to be highly grateful
for this new opportunity for a reasonable life, and rarely complained about the
rigors of living with the LVAD. We even
discovered that some LVAD patients, who were not acceptable for transplant for
social reasons, reorganized their lives to the point where we reconsidered them
and recommended them for transplant.
In spite of the optimism, we encountered patients who did no
thrive on the LVAD, and when they were comatose with little hope of survival
due to overwhelming sepsis, end stage renal failure, or active cancer, we
discussed the need to terminate LVAD support, and after concurrence with all
involved, turned off the pump. Resolving
this ethical issue became a necessity for our VAD program, as there is nothing
worse that having a patient with no brain or heart function continuing with a
normal blood pressure and no hope of recovery.
Because of the ethical issues involved in terminating LVAD
support, it’s no surprise that the issue of turning off a heart support device is becoming increasingly public. ACC BOG
Chair Dick Kovacs, MD, FACC, recently wrote about a New York Times piece examining one family’s
struggle to have a pacemaker turned off. The experience was traumatizing for
all those involved and, as Dick wrote, is a good reminder that the wishes of
the patients need to be fully appreciated. With artificial technology
increasingly being used to prolong life, and with VAD technology improving so
that more patients will likely have these implants, these questions are going
to rise in importance.
Recognizing this, researchers at Mayo recently published a
review of 14 cases where patients
who were being kept alive by an LVAD requested that it be turned off. Mayo
researchers concluded that turning off the LVAD was “ethically and legally
permissible” because practitioners were not introducing a “new pathology” to
induce death; rather, turning off the LVAD allows the heart failure to take its
course. As long as the patients and their family understand what will happen
when the device is turned off, physicians should respect their decision. All the patients had serious complications
that limited their chances of survival even with the VAD, and they or their
families appropriately requested that the VAD be turned off.
The study authors conclude:
Patients have the right to refuse
or request the withdrawal of any unwanted treatment, and we argue that this
right extends to VAD support. We also argue that the cause of death in these
cases is the underlying heart disease, not assisted suicide or euthanasia.
Therefore, patients with heart failure supported with VADs or their surrogates
may request withdrawal of this treatment. In our view, carrying out such
requests is permissible in accordance with the principles that apply to
withdrawing other life-sustaining treatments.
The Mayo study will help clarify what physicians should do
in one very tricky situation. If you are
involved with care of VAD patients, this issue should be addressed as a program
policy so that one physician will not be left to resolve this dilemma.