The human heart is essentially a pump. When the pump does not work well, patients are tired because blood is not sending oxygen to their brain and other tissues. Also, fluid builds up in the legs and other parts of the body, making it difficult to walk and breathe. Patients with a failing heart such as this can sometimes benefit from a heart transplant-- patients need a thorough workup, medications, and a proper diet, among other things. But, there are very few donor hearts available. Is there an alternative?
Ventricular assist devices (VAD) can be used in SELECT patients depending on medical, surgical, and psychosocial factors. These devices are surgically implanted into the body, and attach to the patient's heart, bypassing the heart and becoming the pump (because the heart is no longer an effective pump). Some patients use a VAD for the left side of the heart (LVAD), some for the right side of the heart (RVAD), and some for both sides (biVAD). Some patients use VAD therapy as a bridge while they wait for a heart transplant, others use VAD therapy as their destination-- they will not get a heart transplant; rather, they will rely solely on the VAD as life support. In rare cases, a VAD can be used temporarily to help the heart recover, then the device is removed-- the patient does not need it, or a transplant.
There are several types of VADs in terms of engineering design-- only your surgical team knows which is the best one for your situation. Sometimes patients want to choose their own-- this is unwise and not standard clinical practice. You cannot demand which type of device you want; however, you can refuse devices that are offered to you. For more about this, see: Bramstedt KA, Nash PJ. When death is the outcome of informed refusal: dilemma of rejecting ventricular assist device therapy. J Heart Lung Transplant 2005;24(2):229-30.
Ethicists and VAD Therapy
Transplant ethicists can be key members of VAD Teams. In their role, they have various functions including serving as a patient advocate, performing capacity assessments, drafting consent forms and educational materials, and performing ethics consultations with regard to patient selection, as well as post-implant ethical issues such as non-compliance, futility, treatment refusal, and transplant candidacy.
One of the most critical things to remember about VAD therapy is that it is a form of LIFE SUPPORT. In this manner, it is no different than dialysis, mechanical ventilation (breathing machine) or other forms of life support. Patients are "pump dependent" when they are receiving VAD therapy. Sometimes, clinical situations turn negative and the patient's trajectory is either limbo or a downward spiral. In these situations it is very important to consider if VAD therapy is having any utility or benefit to the patient and how much suffering the patient is experiencing. How is the patient's quality of life impacted?
Adult patients with decision-making capacity have legal and ethical permission to have burdensome or unwanted treatments stopped, even if they are a form of life support and even if death will follow. VAD teams have the ethical and legal obligation to not offer VADs to patients that won't benefit from them (futility) and these teams can stop providing the intervention after implantation (turning device off) if use of the device becomes futile (non-beneficial). If there is any ethical concern, distress, or discomfort, the VAD Team ethicist should be consulted.
At all times, a Palliative Care specialist should be available to the VAD Team as a consultant to help address special concerns that sometimes arise such as nausea, decreased appetite, anxiety, sleep disturbance, pain, or other discomfort. At the end of life, this consultant can work with families to understand the dying process (VAD shut off protocol).
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