Keyur B Shah1, James L Levenson, Mandeep R Mehra. 1. aDivision of Cardiology, Virginia Commonwealth University bDepartment of Psychiatry, Virginia Commonwealth University, Richmond, Virginia cBrigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.
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.
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.