title: Challenges in deactivating a total artificial heart for a patient with capacity.
abstract: The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.
authors.affiliation: Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX. Electronic address: crbruce@bcm.edu.
authors.forename: Courtenay R
authors.initials: CR
authors.lastname: Bruce
authors.affiliation: Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Section of Emergency Medicine, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX.
authors.forename: Nathan G
authors.initials: NG
authors.lastname: Allen
authors.affiliation: Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX; Department of Surgery, Weill Cornell Medical College, Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX; Division of Palliative Medicine, The Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX.
authors.forename: Bridget N
authors.initials: BN
authors.lastname: Fahy
authors.affiliation: Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX.
authors.forename: Harvey L
authors.initials: HL
authors.lastname: Gordon
authors.affiliation: Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist DeBakey Heart and Vascular Center and JC Walter Jr Transplant Center, St. Luke's Episcopal Hospital, Houston, TX.
authors.forename: Erik E
authors.initials: EE
authors.lastname: Suarez
authors.affiliation: Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Texas Heart Institute, St. Luke's Episcopal Hospital, Houston, TX.
authors.forename: Brian A
authors.initials: BA
authors.lastname: Bruckner
mesh_terms: D032921:Consensus; D016638:Critical Illness; D006354:Heart, Artificial / Q000941:ethics*; D006801:Humans; D013727:Terminal Care; D028761:Withholding Treatment / Q000941:ethics* / Q000331:legislation & jurisprudence*