Mayo Clinic Finds Withdrawing Ventricular Assist Device (VAD) Support Ethical

Monday, August 02, 2010

ROCHESTER, Minn. — Patients have the right to refuse or request the withdrawal of any unwanted treatment. In an article published in the online issue of Mayo Clinic Proceedings, investigators explore the legal and ethical permissibility of carrying out such a request specific to a ventricular assist device (VAD).

The left-VAD (LVAD) is a new technology that provides circulatory support for patients with severe heart failure who are awaiting a heart transplant. This technology also can serve as a long-term treatment option for patients who are not candidates for heart transplant, but still need circulatory support, also known as "destination therapy."

Notably, VAD technology is continuously improving. "A recent trial demonstrated significantly greater two-year survival among patients with severe heart failure treated with continuous-flow LVADs than among patients treated with older pulsatile-flow devices (58 percent versus 24 percent)," says Paul Mueller, M.D., lead investigator, Mayo Clinic Department of General Internal Medicine. At Mayo Clinic the two-year survival rate for patients treated with LVAD is 74 percent. Therefore, the VAD is a long-term treatment for patients with severe heart failure.

Nevertheless, some patients treated with VADs experience complications (e.g., stroke) related to their treatment or their underlying disease and request withdrawal of VAD support.

Dr. Mueller and colleagues describe 14 patients who requested (or their surrogates requested) withdrawal of LVAD support and these requests were carried out by their physicians. Dr. Mueller and colleagues then describe the ethical and legal permissibility of carrying out such requests.

"If the patient (or their surrogate) concludes that VAD support is more burdensome than beneficial, they may request withdrawal of VAD support (that is, that the device be turned off)," says Dr. Mueller. "Assuming the patient (or surrogate) is informed regarding alternatives to and consequences of withdrawing VAD support, clinicians should carry out such requests or transfer the patient's care to another physician. The cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia. In our view, carrying out such requests is permissible in accordance with the principles that apply to withdrawing other life-sustaining treatments." Examples are hemodialysis, mechanical ventilation and artificial hydration and nutrition.

A peer-reviewed journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 80 years and has a circulation of 130,000 nationally and internationally. Articles are available online.

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