Thursday, April 24, 2008

Left Ventricular Assist Devices (LVADs) Can Create End-of-Life Ethical Dilemmas

MSNBC is publicizing an important article in the Washington Post that describes why the latest and most effective heart pumps can cause serious end-of-life ethical dilemmas.

Left ventricular assist devices (LVADs) originated as a way to keep damaged hearts functioning while heart-transplant candidates waited for donated organs. But the devices did such a good job that permanent implants are becoming the therapy of choice for patients with chronic heart failure.

The procedure costs about $200,000 and Medicare will pay for it. U.S. centers are implanting about 1,000 per year now. But the experts expect that to rise to 10,000 per year within the next five years.

The ethical problems arise when the devices begin to lose their effectiveness, either with further deterioration of the heart itself or related conditions that leave the patient with little or no quality of life.

The article says that most physicians equate the devices with ventilators, feeding tubes and other forms of life support that patients have the right to stop if their condition deteriorates or becomes intolerable. But others say the devices become a functioning part of the patient's heart, so that to shut off the devices is to do harm and even actively kill the patient.

Given this ethical debate, experts are recommending a lot more counseling and analysis before an individual patient gets an LVAD, including weighing cautiously if a patient is too old or too sick to really benefit from the device. However, this would not be of much help to patients in emergency situations who are not in a position to give informed consent to the procedure.

The article also notes extreme situations where LVAD recipients have become so distressed with their doctors' failure to address end-of-life frustration and pain that the patients have powered off the devices themselves.

Hopefully a new ethical consensus will develop on what options should and should not be available in dealing with this new technology.

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