Ethical analysis of withdrawing ventricular assist device support.

OBJECTIVE: To describe a series of patients with heart failure supported with a ventricular assist device (VAD) who requested (or whose surrogates requested) withdrawal of VAD support and the legal and ethical aspects pertaining to these requests. PATIENTS AND METHODS: We retrospectively reviewed the medical records of patients at Mayo Clinic, Rochester, MN, from March 1, 2003, through January 31, 2009, who requested (or whose surrogates requested) withdrawal of VAD support and for whom the requests were fulfilled. We then explored the legal and ethical permissibility of carrying out such requests. RESULTS: The median age of the 14 patients identified (13 men, 1 woman) was 57 years. Requests were made by 2 patients and 12 surrogates. None of the patients' available advance directives mentioned the VAD. For 11 patients, multidisciplinary care conferences were held before withdrawal of VAD support. Only 1 patient had an ethics consultation. All 14 patients died within 1 day of withdrawal of VAD support. CONCLUSION: Patients have the right to refuse or request the withdrawal of any unwanted treatment, and we argue that this right extends to VAD support. We also argue that the cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia. Therefore, patients with heart failure supported with VADs or their surrogates may request withdrawal of this treatment. In our view, carrying out such requests is permissible in accordance with the principles that apply to withdrawing other life-sustaining treatments.

Report of 255 clinical ethics consultations and review of the literature.

OBJECTIVE: To review clinical ethics consultations at a tertiary care academic medical center. METHODS: We retrospectively reviewed all ethics consultations (and associated patient medical records) conducted at the Mayo Clinic in Rochester, Minn, between April 6, 1995, and December 31, 2005. RESULTS: Of the 255 consultations, 101 (40%) reviewed intensive care unit care, 103 (40%) involved patients who died during hospitalization, and 174 (68%) were requested by physicians. The most common primary diagnoses of the patients involved were malignancy (18%, n=47), neurologic disease (18%, n=47), and cardiovascular disease (17%, n=43). Most cases involved multiple issues: patient competency and decision-making capacity (82%, n=208), staff member disagreement with care plans (76%, n=195), end-of-life and quality-of-life issues (60%, n=154), and goals of care and futility (54%, n=138). Withholding or withdrawing measures was the focus of 132 (52%) of the consultations. We also identified previously published reports of ethics consultations and compared the findings of those reports with ours. CONCLUSIONS: Despite advances in medicine, the nature of ethical dilemmas remains relatively unchanged. Issues of communication, family conflict, and futility continue to give rise to ethical quandaries.