Withdrawal of ventricular assist device support.
OBJECTIVE
Ventricular assist devices (VAD) are mechanical pumps implanted into patients with advanced heart failure who are at risk of imminent death. VADs are a treatment and not a cure, and mortality on device support remains high. Recognizing the dire nature of the decisions for patients and families and the associated high mortality rates, we actively included processes for device withdrawal as part of our program mandate.


METHODS
At Toronto General Hospital, from October 2001 to December 2004, 22 patients underwent implantation of a VAD. Seven patients died following device withdrawal.


RESULTS
The average time spent on support prior to device withdrawal was seven days. In four of the seven cases, family members initiated discussions regarding device withdrawal. Family-initiated discussions were more likely to occur if patients were implanted electively, as a bridge to transplantation. Disagreements occurred between the ICU and the transplant teams regarding the timing of device withdrawal and responsibility for stopping the pump.


CONCLUSIONS
Establishing a process for device withdrawal has been a key factor in the success of our VAD program. This process relies heavily on pre-implantation preparation, a strategy for resolving disagreements, and a process for withdrawing device support.
MacIver
Jane
J
Division of Cardiology, Toronto General Hospital, Ontario, Canada.
Ross
Heather J
HJ
D032722:Advance Care Planning / Q000941:ethics / Q000592:standards*; D001294:Attitude to Health; D002985:Clinical Protocols / Q000592:standards; D003142:Communication; D003299:Cooperative Behavior; D034462:Dissent and Disputes; D017558:Elective Surgical Procedures; D005190:Family / Q000523:psychology; D006333:Heart Failure / Q000401:mortality / Q000523:psychology / Q000601:surgery*; D016027:Heart Transplantation; D006353:Heart-Assist Devices / Q000009:adverse effects / Q000941:ethics / Q000523:psychology / Q000592:standards*; D006769:Hospitals, General; D006801:Humans; D007258:Informed Consent / Q000941:ethics / Q000523:psychology / Q000592:standards; D018447:Medical Futility / Q000941:ethics / Q000523:psychology; D009864:Ontario / Q000453:epidemiology; D010166:Palliative Care / Q000941:ethics / Q000523:psychology / Q000592:standards*; D018579:Patient Selection / Q000941:ethics; D026684:Personal Autonomy; D011300:Preoperative Care / Q000941:ethics / Q000523:psychology / Q000592:standards*; D011368:Professional-Family Relations; D013997:Time Factors; D014850:Waiting Lists; D028761:Withholding Treatment / Q000941:ethics / Q000592:standards*