Online Letters to the Editor
End-of-Life Care and Deactivation of Left Ventricular Assist Devices To the Editor:
I
n a recent issue of Critical Care Medicine, Pratt et al (1) reviewed the anatomical and physiological reconfiguration of the systemic circulation after the implantation of continuous-flow nonpulsatile left ventricular assist devices (LVADs). HeartMate II and HeartWare are valveless pumps that bypass the native aortic valve and connect the left ventricular (LV) cavity to the thoracic aorta (1). Circulatory arrest is generally within minutes after device deactivation if there is no native LV mechanical systole. When LV mechanical systole continues after deactivation, circulatory arrest may be delayed for hours. Switching off the power supply to the pump converts the pump’s functionality into a bidirectional conduit for blood flow from the LV cavity to the thoracic aorta (i.e., pump regurgitation) (2). Pump regurgitation may affect end-of-life care. The changed functionality of the pump can induce acute multiple organ hypoperfusion and ischemic symptoms before circulatory arrest (2). Optimal end-of-life care requires careful assessment and effective palliation of these symptoms. However, no high-quality evidence-based practice guidelines exist for this. In addition, administering sedatives to depress the level of consciousness is generally misinterpreted as synonymous with abolishing internal and external awareness of noxious stimuli (3). Therefore, lacking robust evidence on the effectiveness of symptom assessment and management, the harm from unrecognized distress induced by LVAD deactivation before death should be weighed against the intended benefit of elective deactivation. Pratt et al (1) asserts that LVAD deactivation “at the request of a patient or surrogate is not considered physician-assisted death but rather allowing natural death to occur.” Others disagree. Some legal scholars consider LVAD deactivation “a form of physician-aid-in-dying” (4) or “an act of euthanasia” (5) based on the surgical reconfiguration of the circulation. A substantial number of clinicians (6) also consider LVAD deactivation as a form of euthanasia. We think that end-of-life care practice and decision making should be grounded in clinically trustworthy guidelines rather than opinions that are short of scientific validation and potentially cause more harm than benefit to LVAD patients. For those reasons, more scientific research is needed to optimize end-of-life care and develop high-quality evidence-based practice guidelines. The authors have disclosed that they do not have any potential conflicts of interest.
Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
e534
www.ccmjournal.org
Mohamed Y. Rady, BChir, MB (Cantab), MA, MD (Cantab), FRCS (Eng & Edin), FRCP (UK), FCCM, Department of Critical Care, Mayo Clinic Hospital, Phoenix, AZ; Joseph L. Verheijde, PhD, MBA, PT, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, AZ
REFERENCES
1. Pratt AK, Shah NS, Boyce SW: Left Ventricular Assist Device Management in the ICU. Crit Care Med 2014; 42:158–168 2. Rady MY, Verheijde JL: Ethical considerations in end-of-life deactivation of durable mechanical circulatory support devices. J Palliat Med 2013; 16:1498–1502 3. Deschepper R, Laureys S, Hachimi-Idrissi S, et al: Palliative sedation: Why we should be more concerned about the risks that patients experience an uncomfortable death. Pain 2013; 154:1505–1508 4. Noah L: Turn the beat around? Deactivating implanted cardiac-assist devices. William Mitchell Law Rev 2013; 39:1229–1286 5. Orentlicher D: Deactivating implanted cardiac devices: Euthanasia or the withdrawal of treatment? William Mitchell Law Rev 2013; 39:1287–1294 6. Swetz KM, Cook KE, Ottenberg AL, et al: Clinicians’ attitudes regarding withdrawal of left ventricular assist devices in patients approaching the end of life. Eur J Heart Fail 2013; 15:1262–1266 DOI: 10.1097/CCM.0000000000000278
The authors reply:
W
e appreciate the thoughtful Letter to the Editor by Rady and Verheijde (1) about our article (2). As a new and evolving type of therapy, the concept of deactivating mechanical circulatory support (MCS) is daunting. Questions have been raised as to whether left ventricular assist devices (LVADs) represent replacement or substitute treatment (3, 4). We agree that clinical decision making ought to be grounded in well-reasoned ethical justification, and we also agree that there will always be individuals who hold idiosyncratic moral views. Where we disagree is we believe that there are trustworthy clinical ethics guidelines (5) that already cover this life-extending technology. These guidelines make clear that there has been a long-established consensus that patients or their surrogate(s) have the legal and ethical right to refuse life-extending technologies. This consensus holds also that there is no legal or ethical difference between withholding and withdrawing. Further, these guidelines note the long-standing consensus that forgoing life-extending technologies are legally and ethically distinct from suicide, physicianassisted suicide, and euthanasia. We consider it ethically perilous to advance the notion that stopping the use of an LVAD or, for that matter, any durable MCS devices is morally different from stopping any other lifeextending technology, such as a ventilator, or artificial food and hydration. Although the technical, psychological, and emotional aspects of turning off and/or removing these cardiac assist devices are, indeed, challenging, these aspects of the care July 2014 • Volume 42 • Number 7
End-of-Life Care and Deactivation of Left Ventricular Assist Devices To the Editor:
I
n a recent issue of Critical Care Medicine, Pratt et al (1) reviewed the anatomical and physiological reconfiguration of the systemic circulation after the implantation of continuous-flow nonpulsatile left ventricular assist devices (LVADs). HeartMate II and HeartWare are valveless pumps that bypass the native aortic valve and connect the left ventricular (LV) cavity to the thoracic aorta (1). Circulatory arrest is generally within minutes after device deactivation if there is no native LV mechanical systole. When LV mechanical systole continues after deactivation, circulatory arrest may be delayed for hours. Switching off the power supply to the pump converts the pump’s functionality into a bidirectional conduit for blood flow from the LV cavity to the thoracic aorta (i.e., pump regurgitation) (2). Pump regurgitation may affect end-of-life care. The changed functionality of the pump can induce acute multiple organ hypoperfusion and ischemic symptoms before circulatory arrest (2). Optimal end-of-life care requires careful assessment and effective palliation of these symptoms. However, no high-quality evidence-based practice guidelines exist for this. In addition, administering sedatives to depress the level of consciousness is generally misinterpreted as synonymous with abolishing internal and external awareness of noxious stimuli (3). Therefore, lacking robust evidence on the effectiveness of symptom assessment and management, the harm from unrecognized distress induced by LVAD deactivation before death should be weighed against the intended benefit of elective deactivation. Pratt et al (1) asserts that LVAD deactivation “at the request of a patient or surrogate is not considered physician-assisted death but rather allowing natural death to occur.” Others disagree. Some legal scholars consider LVAD deactivation “a form of physician-aid-in-dying” (4) or “an act of euthanasia” (5) based on the surgical reconfiguration of the circulation. A substantial number of clinicians (6) also consider LVAD deactivation as a form of euthanasia. We think that end-of-life care practice and decision making should be grounded in clinically trustworthy guidelines rather than opinions that are short of scientific validation and potentially cause more harm than benefit to LVAD patients. For those reasons, more scientific research is needed to optimize end-of-life care and develop high-quality evidence-based practice guidelines. The authors have disclosed that they do not have any potential conflicts of interest.
Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
e534
www.ccmjournal.org
Mohamed Y. Rady, BChir, MB (Cantab), MA, MD (Cantab), FRCS (Eng & Edin), FRCP (UK), FCCM, Department of Critical Care, Mayo Clinic Hospital, Phoenix, AZ; Joseph L. Verheijde, PhD, MBA, PT, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, AZ
REFERENCES
1. Pratt AK, Shah NS, Boyce SW: Left Ventricular Assist Device Management in the ICU. Crit Care Med 2014; 42:158–168 2. Rady MY, Verheijde JL: Ethical considerations in end-of-life deactivation of durable mechanical circulatory support devices. J Palliat Med 2013; 16:1498–1502 3. Deschepper R, Laureys S, Hachimi-Idrissi S, et al: Palliative sedation: Why we should be more concerned about the risks that patients experience an uncomfortable death. Pain 2013; 154:1505–1508 4. Noah L: Turn the beat around? Deactivating implanted cardiac-assist devices. William Mitchell Law Rev 2013; 39:1229–1286 5. Orentlicher D: Deactivating implanted cardiac devices: Euthanasia or the withdrawal of treatment? William Mitchell Law Rev 2013; 39:1287–1294 6. Swetz KM, Cook KE, Ottenberg AL, et al: Clinicians’ attitudes regarding withdrawal of left ventricular assist devices in patients approaching the end of life. Eur J Heart Fail 2013; 15:1262–1266 DOI: 10.1097/CCM.0000000000000278
The authors reply:
W
e appreciate the thoughtful Letter to the Editor by Rady and Verheijde (1) about our article (2). As a new and evolving type of therapy, the concept of deactivating mechanical circulatory support (MCS) is daunting. Questions have been raised as to whether left ventricular assist devices (LVADs) represent replacement or substitute treatment (3, 4). We agree that clinical decision making ought to be grounded in well-reasoned ethical justification, and we also agree that there will always be individuals who hold idiosyncratic moral views. Where we disagree is we believe that there are trustworthy clinical ethics guidelines (5) that already cover this life-extending technology. These guidelines make clear that there has been a long-established consensus that patients or their surrogate(s) have the legal and ethical right to refuse life-extending technologies. This consensus holds also that there is no legal or ethical difference between withholding and withdrawing. Further, these guidelines note the long-standing consensus that forgoing life-extending technologies are legally and ethically distinct from suicide, physicianassisted suicide, and euthanasia. We consider it ethically perilous to advance the notion that stopping the use of an LVAD or, for that matter, any durable MCS devices is morally different from stopping any other lifeextending technology, such as a ventilator, or artificial food and hydration. Although the technical, psychological, and emotional aspects of turning off and/or removing these cardiac assist devices are, indeed, challenging, these aspects of the care July 2014 • Volume 42 • Number 7
