title: Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick.
abstract: Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient's best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.
authors.affiliation: Division of Cardiology, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Suite 6215, Los Angeles, CA 90048, USA. ernst.schwarz@cshs.org
authors.forename: Ernst R
authors.initials: ER
authors.lastname: Schwarz
authors.forename: Kiran J
authors.initials: KJ
authors.lastname: Philip
authors.forename: Sinan A
authors.initials: SA
authors.lastname: Simsir
authors.forename: Lawrence
authors.initials: L
authors.lastname: Czer
authors.forename: Alfredo
authors.initials: A
authors.lastname: Trento
authors.forename: Stuart G
authors.initials: SG
authors.lastname: Finder
authors.forename: Laurent A
authors.initials: LA
authors.lastname: Cleenewerck
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000941:ethics* / Q000523:psychology; D019468:Disease Management; D006333:Heart Failure / Q000628:therapy*; D016027:Heart Transplantation / Q000941:ethics*; D006353:Heart-Assist Devices / Q000941:ethics*; D006801:Humans; D018579:Patient Selection; D011788:Quality of Life; D012803:Sick Role / Q000941:ethics*