title: Left ventricular assist device withdrawal: an ethical discussion.
abstract: Specialist palliative care (SPC) services are increasingly integrated with chronic heart failure (CHF) services. Left ventricular assist devices (LVADs) represent an advance in the management of advanced CHF, but may pose ethical challenges for SPC services providing care to this population. The patient received an LVAD as 'bridge-to-heart-transplant,' but subsequently experienced multiple cerebral haemorrhages, resulting in neurological deficits, and severe functional impairment. The risk of further cerebral events precluded ongoing anticoagulation, and she was transferred to an SPC inpatient unit for symptom control and end-of-life care. Following discussion within the multi-disciplinary team and with the patient's family, LVAD support was withdrawn, and the patient died peacefully. This piece reviews the ethical considerations that informed decision-making, in particular, autonomy, informed consent and futility. In addition, the question of the nature of LVADs is debated and how the perceptions of the patient, and others, of the device may influence decision-making around withdrawal of treatment.
authors.affiliation: Palliative Care Service, St Francis Hospice, Dublin, Ireland.|Milford Care Centre, Castletroy, Limerick, Ireland.
authors.forename: Sarah
authors.initials: S
authors.lastname: McLean
authors.affiliation: Department of Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
authors.forename: Tara Ni
authors.initials: TN
authors.lastname: Dhonnchu
authors.affiliation: Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland.
authors.forename: Niall
authors.initials: N
authors.lastname: Mahon
authors.affiliation: Palliative Care Service, St Francis Hospice, Dublin, Ireland.
authors.forename: Regina
authors.initials: R
authors.lastname: McQuillan
authors.affiliation: Institute of Ethics, Dublin City University, Dublin, Ireland.
authors.forename: Bert
authors.initials: B
authors.lastname: Gordijn
authors.affiliation: Palliative Care Service, St Francis Hospice, Dublin, Ireland.|Department of Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
authors.forename: Karen
authors.initials: K
authors.lastname: Ryan
keywords: Clinical decisions; Ethics; Heart failure; Hospice; Palliative