(374) Clinical Ethics in the Setting of Left Ventricular Assist Device Terminal Deactivation

Introduction: As left ventricular assist devices (LVADs) have become a standard therapy for advanced heart failure, the number of patients living with both destination and bridge-to-transplant LVADs has significantly increased. Thousands of patients undergo LVAD implantation each year in the United States alone. Therefore, understanding the ethical considerations surrounding end-of-life care for patients with LVADs is crucial. We systematically reviewed the ethics literature to analyze the ethical considerations for terminal deactivation of LVADs and how mechanical circulatory support teams can ensure that end-of-life care options offered incorporate ethical principles.

Methods: We performed a mixed qualitative and quantitative systematic literature review of ethical considerations for end-of-life care for patients with an LVAD. After removal of duplicates, 1,895 articles underwent dual, independent screening. 179 studies were reviewed for argument quality and analyzed for ethical position, reasons given, and concepts.

Results: The literature describes various strategies and ethical considerations surrounding the terminal deactivation of LVADs. One key emphasis is on ensuring that discussions about device deactivation and end-of-life considerations occur proactively with patients and their caregivers before LVAD implantation. This consultation includes palliative care involvement and the completion of advanced directives, aiming to align treatment plans with patients' values and preferences. In cases where conflicts arise regarding device deactivation, recommendations suggest involving the ethics committee and/or consulting with palliative care to navigate these challenging decisions. The literature underscores the importance of prioritizing patient autonomy in determining the next steps for device management at end-of-life while also considering quality-of-life.

Conclusions: The reality is that planning a “good death” for patients living with an LVAD begins before device implantation. Terminal deactivation of LVADs presents complex ethical challenges, but proactive communication and involvement of palliative care services can help ensure that end-of-life care decisions align with patients' values and preferences, prioritizing patient autonomy and engaging in collaborative decision-making processes.