Life and Death With an LVAD

Left ventricular assist devices (LVADs) are dramatically altering the field of heart failure care. There are pros and cons with the use of these devices, and this Reuter's article does a good job exploring them in simple terms.

Cardiologists need to become more familiar with these devices' limitations, too:

We have to address what is the meaning of death on one of these pumps," said Dr. Valluvan Jeevanandam, chief of cardiac and thoracic surgery at the University of Chicago Medical Center and an investigator for Thoratec's clinical trials.

Roughly 70 percent of patients on the HeartMate II were alive after a year, and nearly 60 percent were alive after two years, according to the latest data.

"It's not hard to imagine a person who has had severe stroke that has impacted both sides of the brain, the kidneys are shutting down, he is on a respirator, but yet the LVAD just keeps churning along," said Martin Smith, a clinical ethicist at the Cleveland Clinic.

Under U.S. law, patients are allowed to ask that implanted devices be turned off. But Dr. Diane Meier, a professor in the department of geriatrics and palliative medicine at the Mount Sinai School of Medicine, said cardiologists are particularly bad at preparing patients for death, especially this kind of death.

Like pacemakers and ventillators, these devices intervene on the natural course of the dying process and when the quality of life declines sufficiently after their use, it is ethical for patients and family members to request such support be withdrawn.

The challenge, of course, is what to do when these members of the care team aren't there...

-Wes

Turning Off Implanted Defibrillators

End-of-life issues with implantable cardiac defibrillators (ICDs) and the need (or not) for deactivation policies is being discussed at the palliative medicine blog, Pallimed.

Shoot on over and lend your $0.02 to the discussion.

-Wes

A Candid Discussion of End-of-Life Decisions

... show-cased vividly by Richard Knox at NPR:

If any situation kindles the impulse to be heroic, it's the threatened death of one's father, mother, spouse or child. The feeling is so primal that we are regularly warned against medical heroism these days, when every community hospital has its intensive care unit and somebody else is paying the bill. Don't, ethicists caution, yield to the temptation to keep your loved one alive beyond any rational purpose.

Among medical personnel the practice is called "flogging," as in, "Don't flog a dead horse."

Who can disagree? Apparently a shrinking American minority. A plethora of polls in recent years consistently shows that more than 4 out of 5 people approve of terminating "extraordinary" life-support measures if the patient has no hope of recovery. Recently the consensus seems to be broadening to not-so-extraordinary measures, such as "tube" feeding and intravenous fluids.

Most of these polls are couched in terms of life support for terminally ill patients. But a 1988 poll of Ohio residents found 88 percent would not want to be "kept alive by extraordinary means if there were only a small chance of living a normal life."

All well and good, but when it's your father-mother-wife-child, the question is no longer academic. Suddenly you need facts and explanations. What's wrong? Can it be treated? If he survives, will he be the same as before? Will he be normal?

I know from 20 years of writing about medicine that even the best physicians often can offer no immediate answers to questions like these. I also know that doctors and nurses vary enormously in their ability and willingness to communicate medical information.

But the next two weeks will teach me anew how hard it is to extract and assimilate the data families need to answer the awful question: "Do you want heroic measures?" I will also learn firsthand that the question is often far from cut-and-dried, as many thoughtful people imagine when they fill out living wills or declare, "I never want to be maintained on a machine."

Well done. Read the whole thing.

-Wes

Treating Our Patients to Death

An excellent essay on futile care by Joseph Sacco, MD appears today in the New York Times.

-Wes