Review: Patients' refusal of treatment should extend to LVAD removal

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Researchers at the Mayo Clinic are proposing patients should have the right to refuse or request withdrawal of ventricular assist devices, according to an article published online June 28 in Mayo Clinic Proceedings.

To study the legalities and ethical principles of patients who requested that left ventricular assist devices (LVADs) be removed, Paul S. Mueller, MD, of the Mayo Clinic in Rochester, Minn., and colleagues used Mayo Clinic records to identify patients who requested (or surrogates who requested) the removal of an LVAD between March 1, 2003, and January 31, 2009.

Mueller and colleagues identified 14 patients (13 men) who requested the removal of an LVAD. All of the patients were diagnosed with heart failure (HF) and had a mean age of 57 years old. The researchers found that of the 14 cases, two requests for removal were made by patients, while 12 were made by surrogates of the patients.

According to the researchers, 11 patients attended multidisciplinary care conference prior to the removal of the device, but only one patient had an ethics consultation. They reported that all 14 of the patients died within one day of device removal.

While the researchers noted that some patients implanted with LVADs experience certain complications such as stroke, recent trials have highlighted the devices' ability to improve survival rates among HF patients.

After evaluating the 14 cases where requests for removal were granted, the researchers found that patients should have the right to refuse or request the withdrawal of LVAD treatment.

The authors concluded that the cause of death in the cases of removal were associated with heart disease, “not assisted suicide or euthanasia.” Additionally, they concluded that the requests are “permissible” and in accordance with other ideologies that apply to other life-sustaining treatments.

"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)," concluded 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.”