Ethics of withdrawing ventricular assist device support

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.