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02/15/2017

Beyond the Destination LVAD

There are many forms of life sustaining treatment available
to patients thanks to advances in medical technology. When a person’s
physiology weakens or fails, devices may be attached or implanted to take over
for organs that can no longer bear the workload of processing, moving, or
taking in the elements needed to keep a body alive. Conceptually, this is
appealing to a society that is as averse to death as are those of us here in
the US. But we still struggle to accommodate the range of needs that crop up
when function is compromised. As an ethicist, the general trend in my work
suggests that the more advanced the technology, the more questions it raises
when it comes time to talk about halting the mechanical support. Among the more
advanced tools for sustaining physiological function is the Left Ventricular
Assist Device, or LVAD, which maintains the circulatory function for persons
with severe heart failure.

There is little doubt that individuals who are eligible for
the device can experience remarkable quality of life gains whether they move on
to receive a heart transplant or receive the implant as a destination
treatment. Recipients of LVADs can typically return to their daily activities,
and enjoy a level of independence not previously possible for persons with
otherwise lethal heart conditions. However, these patients are not just like
everyone else when complications arise. Decisions about how best to manage long
term care for persons who have LVADs can be unexpectedly complex, most notably
when the patient lives outside a major metropolitan city center. In particular,
securing services when such patients suffer non-cardiac health complications after having the device implanted can be
difficult. Consider a patient who is stable with a destination LVAD who
develops end stage renal disease and requires hemodialysis. Outpatient dialysis
centers can be fearful about safely managing the ongoing dialysis treatment for
a patient when they do not have experience with ventricular assist devices. The
same may apply to residential care centers when a patient needs a period of
rehab for an injury unrelated to the heart failure diagnosis. Perhaps the most
challenging circumstance involving resources for LVAD patients who experience
age related cognitive decline and need nursing home level care due to
confusion, impulsivity, and routine self-care deficits. There are no clear
restorative goals, but the need for custodial care can quickly exceed what was
once possible at home, but the LVAD is usually unfamiliar to small town nursing
homes and can be a barrier to securing long term residential care.

This issue raises an important justice question for LVAD
candidates. Should consent for LVADS, when known to be destination devices,
include information about the limitations in assuring other types of services?
If so, how do we assure that this information is delivered in a way that does
not discriminate against patients from more remote areas while favoring those
who live near facilities that routinely care for LVAD patients? 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.

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