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Ann Thorac Surg 1997;63:1223-1224
© 1997 The Society of Thoracic Surgeons
Departments of Psychiatry and Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
The development of implantable left ventricular assist devices (LVADs) opens new vistas in patient care, while simultaneously drawing attention to ethical problems in the use of such technology. Such ethical questions include when and under what conditions we ought to start, stop, or refrain from initiating treatment with such a device. We will briefly review the relevant literature [1, 2] and then consider the issue of when to stop treating, which remains one of the most complex ethical dilemmas that clinicians face.
Futility: Facts Versus Values
Some physicians have turned to the concept of futility as a way of clarifying when to stop life-sustaining therapies. However, attempts to formulate a scientifically rigorous and quantifiable definition of futility have proved more illusory than real [3]. For instance, some proponents of futility have argued that physicians need neither offer nor continue therapies that have proved ineffective in the last 100 similar cases [4]. This definition appeals because of its apparently objective nature but in practice would be virtually impossible to use. With new therapies such as the LVAD, or in complex cases such as those seen in tertiary care centers, there may not be 100 similar cases. Furthermore, memory is notoriously inaccurate in such assessments, and few physicians are in a position to make a statistically rigorous review of on-going acute care decisions. However, even if hard data were reliably available, we would not find them conclusive in deciding to cease treatment. We do not believe that facts alone ought to guide the decision to withdraw life-sustaining treatment. Rather, we recommend that such decisions be viewed as containing radically different types of information, ie, both facts and values [5]. The physician contributes the expert assessment of the outcome of treatment or its cessation. The patient and family, however, are likely to have greater expertise on the patient's spiritual and other values. These values are an essential component in understanding the meaning to the patient of the various options. Some authors note that although a treatment may appear futile to outsiders, they wish to respect the wishes of patients and families even in their choice of potentially futile treatments [6].
We approach decisions to discontinue LVAD treatment in the following manner. First, at the initiation of treatment, we attempt to learn as much as possible about the patient's objectives in seeking treatment, as many of these patients will go on to lose decision-making capacity. The decision to limit treatment is always a difficult one but can become more so when the patient's wishes remain obscure. In many cases, the patient's family will communicate the patient's wishes, and this information can be enormously valuable. In certain jurisdictions, such as New York State, it is difficult to cease life-sustaining treatments without clear and convincing evidence of the patient's wishes. We specifically hope to learn about those circumstances in which the patient would not wish to continue treatment. For instance, some of our patients have been clear that if they cannot live at home, or if they suffer severe and lasting cognitive damage, they would not wish to continue LVAD support.
When we confront circumstances that force us to consider LVAD discontinuation, we make careful assessments of prognosis. However, we do not argue that doctors must base their recommendations exclusively on factual data. Indeed, many patients specifically ask physicians what they personally would choose in such a situation. We recommend that physicians provide both careful data-based assessments of prognosis and subjective assessments, clearly labeled as such. This information may be followed by a recommendation to cease therapy, when appropriate, and a direct question as to whether or not the family concurs with this plan or has reservations.
Such an approach allows for an appropriate balance between factual information and values. Some advocates of patients' rights may find that this approach tips the balance of power unfairly toward the physician. However, we do not find that patients' interests are served by the practice of simply listing options and forcing patients or their loved ones to choose. When no reasonable options exist, autonomy is not served by pretending that choice remains [7]. Rather, many family members experience an exclusively objective presentation as cruelly burdening them with the decision to abandon apparently useful treatments. We prefer to make recommendations and acknowledge that these recommendations are based on facts and our values, as well as on our understanding of the patient's values. We then encourage the patient or family to express different values when they exist. Not all families have concurred with our recommendations to discontinue LVAD therapy. However, we have not encountered a case where we found it necessary or appropriate to discontinue the LVAD in the face of objections from a patient's family.
Do Not Resuscitate Orders and Discontinuing the LVAD
The meaning of a do not resuscitate (DNR) order is radically altered for a patient who is mechanically ventilated and supported with an LVAD, for the chronic treatment of these patients already surpasses the measures envisioned by advanced cardiac life support protocols. To enact a DNR order for a patient receiving LVAD support suggests withdrawing, and not merely withholding, care. Although ethicists have for many years insisted that there is no ethical difference between withdrawing and withholding treatments, many physicians still believe that there is a profound psychological difference between the two [8]. However, there are compelling reasons to view withdrawing and withholding care as morally equivalent. One such justification is described in the landmark case Barber v Los Angeles County Superior Court [9]:
Even though these life support devices are, to a degree "self-propelling", each pulsation of the respirator or each drop of fluid introduced into the patient's body by intravenous feeding devices is comparable to a manually administered injection or item of medication. Hence, "disconnecting" of the mechanical devices is comparable to withholding the manually administered injection or medication.
An additional reason to equate withholding and withdrawing treatment is that doctors who believe that life-sustaining therapies cannot be withdrawn will be forced to deny the technology to some patients who have a small but real possibility of benefit. A trial of LVAD support, with the possibility of withdrawal if unsuccessful, opens up a potentially hopeful option for the gravely ill patient. If no treatment can be withdrawn, such marginally appropriate patients may lose their last chance.
Doctors must explicitly address the discontinuation of the device with the family. It is not appropriate to conceal discontinuation of the device by suggesting vaguely that further resuscitation efforts are no longer appropriate. Not uncommonly, families may agree wholeheartedly with the decision to make a patient DNR and discontinue the LVAD. However, they cannot bring themselves to sign the DNR form, for the act of signing can symbolically force loved ones to feel responsible for the death of the patient. We do not insist on signatures in such cases, nor does New York State law require us to do so. Rather, we explicitly discuss the plan and its likely consequences with the family, and note in the chart that they concur yet prefer not to sign any form. Both the ethics committee and risk managers at our institution support this practice. Pain control and sedation are ethically appropriate to comfort any dying patient, including one for whom life-sustaining measures are discontinued [10].
Does the use of the LVAD and other new technologies radically change end-of-life decision-making? Yes and no. The hallmark of good medical decisions in any era is the appropriate balance of medical opinion and expertise with the patient's values and wishes. The introduction of new technology does not change this fact. However, new devices do force us to reexamine our practices, and to ask when and how it is wise to employ or withdraw a treatment. The use of advance directives may serve as a useful starting point for discussions but cannot substitute for in-depth efforts to learn how patients assess benefits and burdens. We do not believe that any treatment, once initiated, need be maintained once its burdens to the patient outweigh its benefits.
Acknowledgments
Doctor Mehmet C. Oz was supported by an Irving Fellowship.
Footnotes
Address reprint requests to Dr Oz, Department of Surgery, Columbia-Presbyterian Medical Center, 177 Fort Washington Ave, New York, NY 10032 (e-mail: mco2{at}columbia.edu).
References
This article has been cited by other articles:
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  D. M. Dudzinski Ethics Guidelines for Destination Therapy Ann. Thorac. Surg., April 1, 2006; 81(4): 1185 - 1188. [Abstract] [Full Text] [PDF]
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