How should physicians respond to requests for LVAD removal?

Abstract

Mechanical circulatory support devices, including left ventricular assist devices (LVADs), have become mainstream treatment for end-stage heart failure. LVADs are ethically and legally no different than other types of life support, for which patients have a right to decline or withdraw care consistent with the principle of respect for autonomy. However, the realities of LVAD complicate informed consent and shared decision making. LVAD candidates are often older and have multiple illnesses. And life with an LVAD requires a period of comprehension, adaptation, and reintegration. Therefore, clinicians must assess LVAD candidates’ decision-making capacity, screen and possibly consult for depression, seek to understand whether being on LVAD is consistent with patients’ values, consider temporary support options to allow for goals clarification, and ask for help from family and palliative care specialists.