Withdrawal of life sustaining medical devices at the end of life.
I read with interest the letter from McKenna and others describing the evolution of an algorithm to aid decision making in the withdrawal of life-sustaining medical devices (LSMDs) (1). The briefly described scenario involving the development of cancer in a patient with a left ventricular assist device (LVAD) as a bridge to transplantation is familiar to us in cardiovascular medicine, as is the resulting need for decision making in the moment which often becomes the default position.
While the occurrence of this comorbidity could not have been anticipated in this transplant candidate, such events will be increasingly encountered in heart failure patients supported for prolonged periods with LVADs as destination therapy, and given the exponential rise in implant rates, this situation will be commonplace in those surviving with implantable cardioverter defibrillators (ICDs).
While the proposed decision tree provides a useful checklist for LSMD withdrawal, my impression is that at initiation, the protocol appears largely reactive. The flow chart seems to imply that any discussion concerning device withdrawal is broached for the first time at the point of an unanticipated patient request or when the device recipient is subject to what may be a rapidly evolving irrecoverable clinical situation. Any notion of advance care planning is described only in the setting of assessment of capacity relevant to the Mental Capacity Act.
Given the prognostic ambiguity intrinsic to the heart failure disease trajectory, advance care planning might offer significant advantage to these patients and their families encumbered with such uncertainty. While the use of advance directives by those with heart failure is increasing, specific device related decision making remains the exception (2,3). However, preparedness planning for end of life care incorporating palliative care consultations has been shown to be of benefit in those being considered for LVAD therapy (4), and prospective pre-implantation discussion about this issue is mandated in the in the position statement on ICD deactivation from the Heart Rhythm Society in the United states and supported by the European Heart Rhythm Association (5). Such a dialogue would also be necessary as part of the description of the benefits and burdens of device therapy required of an ethically framed valid informed consent process and central to the premise of shared decision making in advanced heart failure (6).
Having been opened prior to device implantation, it would seem appropriate to revisit these end of life care discussions at intervals during follow up, perhaps reducing the complexity of the management of the inevitable crises, and avoiding some of the dilemmas linked to clinical situations such as that described (7). The authors may wish to consider incorporating an element referring to device related advance care planning early in their proposed algorithm.
References 1) McKenna M, Wrightson N, Regnard C, Clark S. Life-sustaining medical devices at the end of life. BMJ Support Palliat Care doi:10.11.1136/bmjspcare-2012-000364. 2) Habal MV, Micevski V, Greenwood S. et al. How aware of advanced care directives are heart failure patients, and are they using them? Canad J Cardiol 2011, 27:376-81. 3) Tajouri TH, Ottenberg AL, Hayes DL, Mueller PS. The use of advance directives among patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol. 2012 , 35:567-73. 4) Swetz KM, Freeman M, AbouEzzeddine OF. et al. Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist devices as destination therapy. Mayo Clin Proc 2011, 86:493-500. 5) Lampert R, Hayes DL, Annas GJ. et al. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) inpatients nearing end of life or requesting withdrawal of therapy. Heart Rhythm. 2010, 7:1008-26. 6) Allen LA, Stevenson LW, Grady KL. et al. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 2012, 125:1928-52. Kirkpatrick JN, Fedson SE, Verdino R. Ethical dilemmas in device treatment for advanced heart failure. Curr Opin Support Palliat Care. 2007, 1:267-73.
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