Left ventricular assist device withdrawal: an ethical discussion
- Sarah McLean1,2,
- Tara Ni Dhonnchu3,
- Niall Mahon4,
- Regina McQuillan1,
- Bert Gordijn5 and
- Karen Ryan1,3
- 1Palliative Care Service, St Francis Hospice, Dublin, Ireland
- 2Milford Care Centre, Castletroy, Limerick, Ireland
- 3Department of Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- 4Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
- 5Institute of Ethics, Dublin City University, Dublin, Ireland
- Correspondence to Dr Sarah McLean, SpR in Palliative Medicine, Milford Care Centre, Castletroy, Co. Limerick, Ireland;
Specialist palliative care (SPC) services are increasingly integrated with chronic heart failure (CHF) services. Left ventricular assist devices (LVADs) represent an advance in the management of advanced CHF, but may pose ethical challenges for SPC services providing care to this population.
The patient received an LVAD as ‘bridge-to-heart-transplant,’ but subsequently experienced multiple cerebral haemorrhages, resulting in neurological deficits, and severe functional impairment. The risk of further cerebral events precluded ongoing anticoagulation, and she was transferred to an SPC inpatient unit for symptom control and end-of-life care. Following discussion within the multi-disciplinary team and with the patient's family, LVAD support was withdrawn, and the patient died peacefully. This piece reviews the ethical considerations that informed decision-making, in particular, autonomy, informed consent and futility. In addition, the question of the nature of LVADs is debated and how the perceptions of the patient, and others, of the device may influence decision-making around withdrawal of treatment.
- Received 14 August 2012.
- Revision received 27 November 2012.
- Accepted 6 December 2012.
- Published Online First 7 January 2013
- Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions