"Doctor, Will You Turn Off My LVAD?"
- "Doctor, Will You Turn Off My LVAD?"
Mr. P is a 62-year-old man with an extensive history of heart disease and severe heart failure. He underwent coronary bypass surgery ten years ago and has had two heart attacks in the past five years. His quality of life has been deteriorating due to his increasing inability to independently perform many daily activities. He currently lives with his wife and daughter.
Eight months ago, as a result of severely debilitating stage IV heart failure, doctors implanted a Left Ventricular Assist Device into Mr. P's chest as so-called destination therapy. The LVAD helps the heart to maximize the volume of blood it pumps into the body. However, many of the device's controls, as well as its power source (a rechargeable battery), are outside the patient and connected to the pump by tubes and wires that pass through the patient's abdominal wall. Originally used only as a "bridge" to support hospital-bound patients for whom a heart transplant was both urgent and imminent, LVADs are now also used as destination therapy for patients who are ineligible for a transplant. In such cases, patients are sent home with LVADs, which are considered the final stage of treatment for their heart failure.
Mr. P's doctors had told him that the LVAD would improve his capacity for self-care and allow him to lead a more active life. However, his health after its implantation was compromised by chronic wound infections, sepsis, and renal failure. He spent the first five months following the implantation in the hospital; during much of this time, he was in the intensive care unit. He eventually returned to his home but has continued to grow weaker. He now sleeps a great deal, eats poorly, walks little, and needs help to go to the bathroom. He also complains of significant pain.
After three months at home, Mr. P has asked to be readmitted to the hospital so that doctors can disable his LVAD. He understands that he will likely die within hours after the device is turned off, but he no longer wishes to live in his current state. In particular, he cites the indignity of being helped to the toilet and his continuing debilitating fatigue as reasons for his request.
Should Mr. P's physicians accede to his request and disable his LVAD?
- Commentary
Although LVADs originally supported patients only for a brief time before they received heart transplants, implantation of the devices has recently evolved into a definitive destination treatment for severe heart failure. Therefore, their use is no longer restricted by the supply of transplantable hearts. This use of destination LVADs will become even more frequent now that Medicare covers the cost of their implantation and maintenance. However, Mr. P is the harbinger not just of future LVAD patients, but of a much larger group we will undoubtedly soon encounter—those who have implanted artificial organs essential to their survival. Although LVADs are neither fully implantable nor a full replacement for a heart, they share many ethically relevant features with true artificial organs. These features would make me reluctant to accede to Mr. P's request.
It is tempting to equate Mr. P's situation to requests for removal of life support—cases where respect for autonomy mandates accommodating the patient. However, these cases differ from Mr. P's in several ways. Most importantly, destination LVADs are implanted into patients and, once implanted, can perform their functions independently of hospital-based equipment or even medical intervention. They are meant for patients to live with at home. Once the patient leaves the hospital, the LVAD ceases to be a medical treatment and becomes effectively part of the patient himself, much like a transplanted organ or even a native one. The fact that the LVAD is manufactured and partially external is less important than the fact that it forms an integrated part of an independently functioning organism. We would not remove a patient's biological heart, transplanted or native, simply because the patient was suffering greatly from heart failure and did not want to go on; nor should we disable his LVAD...
