Allowing Patients to Refuse VAD Support Is Ethical, Mayo Review Concludes

Reed Miller

August 18, 2010

August 17, 2010 (Updated August 19, 2010) (Rochester, Minnesota) — Withdrawing ventricular assist device (VAD) support at the request of the patient or their surrogate is ethical and not tantamount to physician-assisted suicide, an ethics review published online June 28, 2010 in Mayo Clinic Proceedings concludes [1].

"Patients have the right to refuse or request the withdrawal of any unwanted treatment, and . . . this right extends to VAD support," Dr Paul Mueller (Mayo Clinic, Rochester, MN) and colleagues conclude. "The cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia."

Explaining the motivation for writing the review, coauthor Dr Keith Swetz, the practice chair for palliative medicine at Mayo Clinic, told heartwire. "As we saw more of these devices implanted, complications and untoward outcomes became more of a norm, and as we've had more and more patients who've done well, we've had more patients who have not done so well, and the question arose: if a decision was made to turn off the VAD completely in accord with what the patient's previously stated wishes were, was that something that was permissible? There was some variability in the level of comfort with certain providers with that, and that was the impetus for us to look at this in greater detail.

"We hope that the paper will provide guidance for ethics consultation at centers where there may not be the level of comfort that we have with withdrawing these device therapies," Mueller told heartwire. Mueller was also part of the group that wrote the recent HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy.

A group of physicians, nurses, and ethics experts led by Mueller reviewed records of 14 patients at Mayo from 2003 to 2009 who were taken off VAD support. The patients had been supported by the device for as little as one day in one case to 1028 days in another. In two cases, the patient requested the withdrawal, while the patient's surrogate made the decision in the other 12 cases because the patient was incapacitated. None of the patients' available advance directives mentioned the VAD. All patients died within a day of withdrawing the VAD.

These 14 case reports represent the largest series of patients who died after VAD support was withdrawn at their own or their surrogates' request in the published literature, according to the authors, but requests to withdraw VAD support are not uncommon. The 14 patients represent 21% of the total of 68 patients who were implanted with a VAD during the six-year study period, the authors note.

The authors acknowledge that some people believe that withdrawing support knowing that the patient will soon die without it is akin to assisted suicide or euthanasia. However, they argue that "VAD support differs from assisted suicide and euthanasia in important ways. In both assisted suicide and euthanasia, the proximate cause of death is a new pathology prescribed or administered by a clinician with the intention of terminating the patient’s life. In contrast, when a patient dies after withdrawal of a life-sustaining treatment, the cause of death is dependent on the underlying disease; a new pathology has not been introduced. . . . A death that follows withdrawal of VAD support is causally dependent on the underlying heart failure, and the act of withdrawing VAD support removes an impediment to that underlying cause."

They cite ethical and legal consensus establishing that patients or their surrogates may autonomously request the withdrawal of life-sustaining treatments that are ineffective or if they judge the treatment to be more burdensome than beneficial. And physicians commonly comply with requests to withdraw support from mechanical ventilation, hemodialysis, artificial hydration and nutrition, ICDs, or pacemakers under "appropriate conditions."

"VAD technology is very promising. . . . We don't want to condemn this technology because it helps a lot of people," Mueller told heart wire . But in the most of the cases where VAD support is withdrawn, the patients do not have decision-making ability, are suffering multiorgan failure, and are dependent on several different therapies in addition to the VAD, such as an ICD or pacemaker, dialysis, a nutrition-support feeding tube, or mechanical ventilation. "We're maintaining circulation, but is the patient progressing, and is this a meaningful situation for the patient? If they could make the decision for themselves, would they want to be in this situation?"

Swetz added, "From a heart-failure perspective, the majority of these patients may be doing okay. The conundrum rarely becomes that the device isn't helping the person's heart failure. The conundrum is that multiple other medical problems are mounting."

Mueller pointed out that half of the patients in the study did not have an advance directive or living will. "We need to enhance advance-care planning before the patient loses decision-making capacity and make sure that the decisions we are making and that their families or surrogates are making are consistent with what their wishes would be."

It is important that our technology not advance beyond our humanity.

As result of this study and cases, Mayo Clinic now orders proactive palliative-medicine consultations for all patients receiving a VAD, and that process has led to much better advance planning, Mueller said. Mayo physicians are planning to soon publish a paper explaining their approach to helping patients prepare for end-of-life care.

Dr Lynne Warner Stevenson (Harvard Medical School, Boston, MA), the director of the cardiomyopathy and heart-failure program at Brigham and Women's Hospital, "agrees strongly" with the conclusions of Mueller et al. She told heartwire , "Patients or their proxies are completely within their rights to have any form of care discontinued; otherwise, it can be considered assault.

"As we develop life-supporting technology, it is important that our technology not advance beyond our humanity. Most of our therapies remain palliative rather than curative. VADs can enhance survival with excellent quality of life, but they do not confer immunity to other conditions, nor do they confer immortality," Stevenson said.