Esther S Pak1, Christopher A Jones2, Paul J Mather3. 1. Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA. Esther.Pak@pennmedicine.upenn.edu. 2. University of Pennsylvania, Hospice & Palliative Care Medicine, Philadelphia, PA, 19104, USA. 3. Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA. Paul.Mather@pennmedicine.upenn.edu.
Abstract
PURPOSE OF REVIEW: Although the utilization of mechanical circulatory support (MCS) devices is increasing, ethical dilemmas regarding device deactivation and dying process persist, potentially complicating delivery of optimal and compassionate care at end-of-life (EOL). This review aims to study EOL challenges, left ventricular assist devices (LVADs) as a nuanced life support treatment, legal history in the US impacting EOL care, and suggestions to improve EOL care for patients on MCS support. RECENT FINDINGS: Recent studies have demonstrated challenging aspects of EOL care for patients on LVAD support: low use of advanced directives, high rates of surrogate decision-making due to lack of patient capacity, difficult decision-making involving LVAD deactivation even with cooperating patients, and high rates of death in the hospital and ICU settings. Recent studies also suggest lack of consensus even among clinicians in approaching LVAD deactivation as beliefs equating LVAD deactivation with physician-assisted suicide and/or euthanasia remain. Optimal care at EOL will likely require collaborative efforts among multiple specialties, caregivers, and patients. In light of the complex medical, logistical, and ethical challenges in EOL care for LVAD patients, there is room for improvement by multidisciplinary efforts to reach consensus about LVAD deactivation and best practices for EOL care, development and implementation of LVAD-specific advance planning, and protocols for LVAD deactivation. Programmatic involvement of hospice and palliative care in the continuum of care of LVAD patients has the potential to increase and improve advance care planning, support surrogate decision-making, improve EOL compassionate care, and to support caregivers.
PURPOSE OF REVIEW: Although the utilization of mechanical circulatory support (MCS) devices is increasing, ethical dilemmas regarding device deactivation and dying process persist, potentially complicating delivery of optimal and compassionate care at end-of-life (EOL). This review aims to study EOL challenges, left ventricular assist devices (LVADs) as a nuanced life support treatment, legal history in the US impacting EOL care, and suggestions to improve EOL care for patients on MCS support. RECENT FINDINGS: Recent studies have demonstrated challenging aspects of EOL care for patients on LVAD support: low use of advanced directives, high rates of surrogate decision-making due to lack of patient capacity, difficult decision-making involving LVAD deactivation even with cooperating patients, and high rates of death in the hospital and ICU settings. Recent studies also suggest lack of consensus even among clinicians in approaching LVAD deactivation as beliefs equating LVAD deactivation with physician-assisted suicide and/or euthanasia remain. Optimal care at EOL will likely require collaborative efforts among multiple specialties, caregivers, and patients. In light of the complex medical, logistical, and ethical challenges in EOL care for LVAD patients, there is room for improvement by multidisciplinary efforts to reach consensus about LVAD deactivation and best practices for EOL care, development and implementation of LVAD-specific advance planning, and protocols for LVAD deactivation. Programmatic involvement of hospice and palliative care in the continuum of care of LVAD patients has the potential to increase and improve advance care planning, support surrogate decision-making, improve EOL compassionate care, and to support caregivers.
Entities:
Keywords:
End-of-life care; Hospice; Life support treatment; Mechanical circulatory support; Palliative care
Authors: Anna Kowalczys; Michał Bohdan; Alina Wilkowska; Iga Pawłowska; Leszek Pawłowski; Piotr Janowiak; Ewa Jassem; Małgorzata Lelonek; Marcin Gruchała; Piotr Sobański Journal: Front Cardiovasc Med Date: 2022-09-27
Authors: Sarah Chuzi; Adeboye Ogunseitan; Kenzie A Cameron; Kathleen Grady; Lauren Schulze; Jane E Wilcox Journal: J Am Heart Assoc Date: 2021-07-26 Impact factor: 5.501