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Pottash M, Rao A. The Complex Ethical and Moral Experience of Left Ventricular Assist Device Deactivation. J Pain Symptom Manage 2024; 67:274-278. [PMID: 37984719 DOI: 10.1016/j.jpainsymman.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The left ventricular assist device (LVAD) is a fully implantable cardiac replacement device that can complicate the process of dying. We present a case of a patient who attempted to deactivate the LVAD without the support of his medical team. This action was understood as a "suicide attempt" though when the patient was later felt to be dying, LVAD deactivation proceeded without reference to psychiatric illness. To understand this case, we discuss the ethics of LVAD deactivation in the dying process. We then explore the experience of clinicians and the public encountering this unique technology across clinical contexts. We herein present a novel and possibly controversial analysis of the moral complexities of LVAD deactivation and suggest that clinicians be transparent about these complexities with patients and families.
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Affiliation(s)
- Michael Pottash
- Division of Palliative Medicine, Department of Medicine (M.P., A.R.), MedStar Washington Hospital Center, Washington, DC, USA; Georgetown University School of Medicine (M.P., A.R.), Washington, DC, USA.
| | - Anirudh Rao
- Division of Palliative Medicine, Department of Medicine (M.P., A.R.), MedStar Washington Hospital Center, Washington, DC, USA; Georgetown University School of Medicine (M.P., A.R.), Washington, DC, USA
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2
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Adams DM. Clinical Ethics and Professional Integrity: A Comment on the ASBH Code. HEC Forum 2023:10.1007/s10730-023-09516-z. [PMID: 38127244 DOI: 10.1007/s10730-023-09516-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 12/23/2023]
Abstract
The Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants instructs clinical ethics consultants to preserve their professional integrity by "not engaging in activities that involve giving an ethical justification or stamp of approval to practices they believe are inconsistent with agreed-upon standards" (ASBH, 2014, p. 2). This instruction reflects a larger model of how to address value uncertainty and moral conflict in healthcare, and it brings up some intriguing and as yet unanswered questions-ones that the drafters of the Code, and the profession more broadly, should seek to address in upcoming revisions. The objective of this article is to raise these questions as a way of urging greater clarification of the Code's overall approach to professional integrity, its meaning, and implications.
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Affiliation(s)
- David M Adams
- Department of Philosophy, California State Polytechnic University, Pomona, CA, USA.
- Pomona Valley Hospital Medical Center, Pomona, CA, USA.
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3
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Zaidi D, Kirkpatrick JN, Fedson SE, Hull SC. Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework. JACC. HEART FAILURE 2023; 11:1481-1490. [PMID: 37768252 DOI: 10.1016/j.jchf.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/06/2023] [Accepted: 08/08/2023] [Indexed: 09/29/2023]
Abstract
Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.
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Affiliation(s)
- Danish Zaidi
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Savitri E Fedson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA; Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA.
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4
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Roggi S, Picozzi M. Is Left Ventricular Assist Device Deactivation Ethically Acceptable? A Study on the Euthanasia Debate. HEC Forum 2021; 33:325-343. [PMID: 32253568 PMCID: PMC8585806 DOI: 10.1007/s10730-020-09408-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the last decades, new technologies have improved the survival of patients affected by chronic illnesses. Among them, left ventricular assist device (LVAD) has represented a viable solution for patients with advanced heart failure (HF). Even though the LVAD prolongs life expectancy, patients' vulnerability generally increases during follow up and patients' request for the device withdrawal might occur. Such a request raises some ethical concerns in that it directly hastens the patient's death. Hence, in order to assess the ethical acceptability of LVAD withdrawal, we analyse and examine an ethical argument, widely adopted in the literature, that we call the "descriptive approach", which consists in giving a definition of life-sustaining treatment to evaluate the ethical acceptability of treatment withdrawal. Focusing attention on LVAD, we show criticisms of this perspective. Finally, we assess every patient's request of LVAD withdrawal through a prescriptive approach, which finds its roots in the criterion of proportionality.
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Affiliation(s)
- Sara Roggi
- Center for Clinical Ethics (CREC), Doctoral School in Clinical and Experimental Medicine and Medical Humanities, Biotechnologies and Life Sciences Department, Insubria University, Via Ottorino Rossi 9, 21100 Varese, Italy
- Centre de Recherche sur le Liens Sociaux (CERLIS), Doctoral School 180 in Human et Social Sciences: Cultures, Individuals and Societies, Paris Descartes University, Galerie Gerson, 1st Floor, 54, Rue Saint Jacques, 75005 Paris, France
| | - Mario Picozzi
- Center for Clinical Ethics, Biotechnologies and Life Sciences Department, Insubria University, Via Ottorino Rossi 9, 21100 Varese, Italy
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Hansson SO. The ethics of explantation. BMC Med Ethics 2021; 22:121. [PMID: 34496854 PMCID: PMC8428100 DOI: 10.1186/s12910-021-00690-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the increased use of implanted medical devices follows a large number of explantations. Implants are removed for a wide range of reasons, including manufacturing defects, recovery making the device unnecessary, battery depletion, availability of new and better models, and patients asking for a removal. Explantation gives rise to a wide range of ethical issues, but the discussion of these problems is scattered over many clinical disciplines. METHODS Information from multiple clinical disciplines was synthesized and analysed in order to provide a comprehensive approach to the ethical issues involved in the explantation of medical implants. RESULTS Discussions and recommendations are offered on pre-implantation information about a possible future explantation, risk-benefit assessments of explantation, elective explantations demanded by the patient, explantation of implants inserted for a clinical trial, patient registers, quality assurance, routines for investigating explanted implants, and demands on manufacturers to prioritize increased service time in battery-driven implants and to market fewer but more thoroughly tested models of implants. CONCLUSION Special emphasis is given to the issue of control or ownership over implants, which underlies many of the ethical problems concerning explantation. It is proposed that just like transplants, implants that fulfil functions normally carried out by biological organs should be counted as supplemented body parts. This means that the patient has a strong and inalienable right to the implant, but upon explantation it loses that status.
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Affiliation(s)
- Sven Ove Hansson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Puri K, Malek J, de la Uz CM, Lantos J, Cabrera AG, Frugé E. Allowing Adolescents to Weigh Benefits and Burdens of High-stakes Therapies. Pediatrics 2019; 144:peds.2018-3714. [PMID: 31167936 DOI: 10.1542/peds.2018-3714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2018] [Indexed: 11/24/2022] Open
Abstract
We present the case of a girl aged 17 years and 10 months who has a strong family history of long QT syndrome and genetic testing confirming the diagnosis of long QT syndrome in the patient also. She was initially medically treated with β-blocker therapy; however, after suffering 1 episode of syncope during exertion, she underwent placement of an implantable cardioverter defibrillator. Since then, she has never had syncope. However, during the few months before this presentation, she experienced shocks on multiple occasions without any underlying arrhythmias. These shocks are disconcerting for her, and she is having significant anxiety about them. She requests the defibrillator to be inactivated. However, her mother, who also shares the diagnosis of long QT syndrome, disagrees and wants the defibrillator to remain active. The ethics team is consulted in this setting of disagreement between an adolescent, who is 2 months shy of the age of maturity and medical decision-making, and her mother, who is currently responsible for her medical decisions. The question for the consultation is whether it would be ethically permissible for the doctors to comply with the patient's request to turn off the defibrillator or whether the doctors should follow the mother's wishes until the patient is 18 years of age.
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Affiliation(s)
- Kriti Puri
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas;
| | - Janet Malek
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Caridad Maylin de la Uz
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - John Lantos
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri; and
| | - Antonio Gabriel Cabrera
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Ernest Frugé
- Section of Hematology-Oncology, Department of Pediatrics, Center for Medical Ethics and Health Policy, Baylor College of Medicine and Texas Children's Cancer and Hematology Centers, Houston, Texas
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Abstract
Along with the growing utilization of the total artificial heart (TAH) comes a new set of ethical issues that have, surprisingly, received little attention in the literature: (1) How does one apply the criteria of irreversible cessation of circulatory function (a core concept in the Uniformed Determination of Death Act) given that a TAH rarely stops functioning on its own? (2) Can one appeal to the doctrine of double effect as an ethical rationale for turning off a TAH given that this action directly results in death? And, (3) On what ethical grounds can a physician turn off a TAH in view of the fact that either the intent of such an action or the outcome is always, and necessarily, death? The aim of this article is not to answer these questions but to highlight why these questions must be explored in some depth given the growing use of TAH technology.
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Swetz KM, Wordingham SE, Armstrong MH, Koepp KE, Ottenberg AL. Hospice and Palliative Medicine Clinician Views of Deactivation of Ventricular Assist Devices at the End of Life. J Pain Symptom Manage 2015; 50:e6-8. [PMID: 26025277 DOI: 10.1016/j.jpainsymman.2015.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/16/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Sara E Wordingham
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Katlyn E Koepp
- Division of General Internal Medicine, Department of Medicine, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, USA
| | - Abigale L Ottenberg
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, USA
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Karches KE, Sulmasy DP. Ethical considerations for turning off pacemakers and defibrillators. Card Electrophysiol Clin 2015; 7:547-55. [PMID: 26304534 DOI: 10.1016/j.ccep.2015.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The 2010 guidelines regarding management of cardiovascular implantable electronic devices (CIEDs) conclude that patient requests to deactivate these devices at the end of life should be honored. Nevertheless, many clinicians and patients report feeling uncomfortable discontinuing such therapies, particularly pacemakers. If the principles of clinical ethics are followed, turning off CIEDs at the end of life is morally permissible. Clinicians managing CIEDs should discuss the option of deactivation with the patient at the time of implantation and be prepared to reopen the question as warranted by the patient's clinical course and respect for the patient's authentic values.
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Affiliation(s)
- Kyle E Karches
- Department of Medicine, The University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Daniel P Sulmasy
- Department of Medicine and Divinity School, The University of Chicago Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Bruce CR, Allen NG, Fahy BN, Gordon HL, Suarez EE, Bruckner BA. Challenges in deactivating a total artificial heart for a patient with capacity. Chest 2014; 145:625-631. [PMID: 24590023 DOI: 10.1378/chest.13-1103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.
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Affiliation(s)
- Courtenay R Bruce
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX.
| | - Nathan G Allen
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Section of Emergency Medicine, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX
| | - Bridget N Fahy
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX; Department of Surgery, Weill Cornell Medical College, Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX; Division of Palliative Medicine, The Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX
| | - Harvey L Gordon
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX
| | - Erik E Suarez
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist DeBakey Heart and Vascular Center and JC Walter Jr Transplant Center, St. Luke's Episcopal Hospital, Houston, TX
| | - Brian A Bruckner
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Texas Heart Institute, St. Luke's Episcopal Hospital, Houston, TX
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11
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Bruce CR, Brody B, Majumder MA. Ethical dilemmas surrounding the use of ventricular assist devices in supporting patients with end-stage organ dysfunction. Methodist Debakey Cardiovasc J 2013; 9:11-4. [PMID: 23518898 DOI: 10.14797/mdcj-9-1-11] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Successful practice of cardiovascular medicine requires familiarity with the complex ethical issues that accompany therapeutic innovation and diffusion. Even as technologies transition from experimental to standard care, challenges remain. Mechanical circulatory support devices, for instance, are increasingly conceptualized as conventional therapies. Despite this, or perhaps because of it, the ethical issues surrounding the use of these devices in patients with end-stage organ dysfunction are becoming increasingly apparent. In this paper, we provide an introduction to ethical considerations related to the use of ventricular assist devices (VADs) in end-stage organ failure, focusing on three stages or decision points: initiation, continued use, and deactivation. Our goal is not to exhaustively resolve these dilemmas but to illustrate how ethical considerations relate to decision making.
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12
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Malpas PJ, Cooper L. The Ethics of Deactivating a Pacemaker in a Pacing-Dependent Patient. Am J Hosp Palliat Care 2012; 29:566-9. [DOI: 10.1177/1049909111432624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The decision to deactivate a pacemaker in a pacing-dependent patient is troubling for some health professionals who may regard such interventions as hastening death and therefore ethically impermissible. This may be especially concerning in situations where a patient is unable to clearly state what their preferences may be and the decision—were it to be made—will almost certainly result in the patient’s immediate death. In this discussion, we reflect on some of the ethical aspects that arise when JP, a 75-year-old woman who is pacing dependent, suffers a significant brain injury, and the family request that her pacemaker be deactivated. Taking into account the clinical reality of her situation, the united wishes and loving concern of her husband and family, and their substituted judgment regarding her likely preferences, we claim that the decision to deactivate her pacemaker was ethically sound.
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Affiliation(s)
- Phillipa J. Malpas
- Department of Psychological Medicine, The University of Auckland, University of Auckland, New Zealand
| | - Lisa Cooper
- Physiology Department, Auckland City Hospital, Auckland, New Zealand
- New Zealand Certificate of Science (NZCS)
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13
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Rady MY, Verheijde JL. End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die? BMC Med Ethics 2010; 11:15. [PMID: 20843327 PMCID: PMC2949779 DOI: 10.1186/1472-6939-11-15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 09/15/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die." DISCUSSION Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death. SUMMARY Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy.
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Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, Arizona, 85054, USA
- Center for Biology and Society, School of Life Sciences, Arizona State University, 300 East University Drive, Tempe, Arizona, 85287, USA
| | - Joseph L Verheijde
- Center for Biology and Society, School of Life Sciences, Arizona State University, 300 East University Drive, Tempe, Arizona, 85287, USA
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, Arizona, 85054, USA
- Department of Biomedical Ethics, College of Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, Arizona, 85054, USA
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14
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Abstract
As Implantable Cardioverter Defibrillators (ICDs) have become more common, ethical issues have arisen regarding the deactivation of these devices. Goldstein et al., have shown that both patients and cardiologists consider ICD deactivation to be different from the discontinuation of other life-sustaining treatments. It cannot be argued ethically that ICDs raise new questions about the distinction between withholding and withdrawing treatment, and neither the fact that they are used intermittently, nor the duration of therapy, nor the mere fact that they are located inside the body can be considered unique to these devices and morally decisive. However, frequent allusions to the fact that they are located inside the body might provide a clue about what bothers patients and physicians. As technology progresses, some interventions seem to become a part of the patient as a unified whole person, completely replacing body parts and lost physiological functions rather than merely substituting for impaired structure and function. If a life-sustaining intervention can be considered a "replacement"--a part of the patient as a unified whole person--then it seems that deactivation is better classified as a case of killing rather than a case of forgoing a life-sustaining treatment. ICDs are not a "replacement" therapy in this sense. The deactivation of an ICD is best classified, under the proper conditions, as the forgoing of an extraordinary means of care. As technology becomes more sophisticated, however, and new interventions come to be best classified as "replacements" (a heart transplant would be a good example), "discontinuing" these interventions should be much more morally troubling for those clinicians who oppose euthanasia and assisted suicide.
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Affiliation(s)
- Daniel P Sulmasy
- John J. Conley Department of Ethics, St. Vincent's Hospital-Manhattan, 153 W. 11th St., New York, NY, USA.
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