Beliefs regarding deactivation of left ventricular assist devices (LVADs) differ significantly between cardiologists and hospice and palliative medicine clinicians (HPMCs), leading to incoherent end-of-life care for some patients, according to a new study in the Journal of Cardiac Failure.
Thirteen percent of cardiologists surveyed believed deactivation of an LVAD was equal to “euthanasia or physician-assisted suicide” compared to zero percent of the HPMC respondents. In addition, 60 percent of cardiologists believed a patient should be “imminently dying” to deactivate an LVAD versus 2 percent of HPMCs.
“Our study highlights several LVAD-specific situations that cardiology and HPM clinicians view differently, chief among them whether a patient should be imminently dying or not to honor one's request for LVAD deactivation,” wrote lead author Colleen K. McIlvennan, DNP, ANP, and colleagues. “This type of fundamental difference of opinion can create inconsistent care for patients—leading to confusion for patients, loved ones, and other health care providers.”
The researchers interpreted their findings from 391 people who completed a 41-item survey delivered via email. Cardiology clinicians—including physicians, nurse practitioners and physician assistants—comprised 68.8 percent of the respondents, with HPMCs representing the rest.
The study included quantitative and qualitative comparisons of clinicians in both specialties. A sample of survey responses accompanied the results, shedding light on a gap in ethical perspectives.
“Turning it off under any other circumstance is directly intervening with the intention of hastening death, which is unethical,” wrote one cardiologist respondent.
On the other hand, an HPMC said patients or their surrogates should always have the option to deactivate an LVAD.
“They underwent this procedure to place the LVAD with consent and had the option to refuse care,” the physician wrote. “They should still have that right at any time. Just because the device is internal does not make it permanent or irreversible.”
In the U.S. an LVAD is considered a life support treatment, and patients or their power of attorneys can request deactivation. If a clinician doesn’t support that decision, “it is the clinician's professional responsibility to transfer care to someone who can carry out the patient's wishes,” McIlvennan et al. wrote.
In the study, 26 percent of cardiologists and 59 percent of HPMCs said they would be “comfortable” personally turning off the device. The same percentage of cardiologists (26 percent) said they would be comfortable ordering the deactivation, compared to 92 percent of HPMCs.
McIlvennan and co-authors noted their response rate—440 out of 7,168 individuals completed the survey—was a limitation of their study. In addition, they didn’t analyze the difference in beliefs of clinicians from North America and Europe, which could be significant given cultural, ethical and legal variations. However, the respondents in the cardiology group were split evenly between the continents.