Ethical challenges and terminal deactivation of left ventricular assist device

Heart failure is one of the most important cardiovascular problems in the United States with 5.7 million adults afflicted in 2015 (1). Left ventricular assist devices (LAVD) implantation in patients with congestive heart failure has excellent outcomes when compared to medical therapy (2,3) and has become an important option for the treatment of patients with advanced heart failure (4-6). Currently, approximately 5,000 to 6,000 patients are treated annually with LVADs (7). Nowadays, the number of LVAD implantations exceeds the number of annual heart transplantations worldwide (6). LVADs are used as a bridge to recovery, a bridge to transplant (BTT), a bridge to decision, and as destination therapy (DT) (6). This rapid increase in the use of LVAD, and modalities of use, raised ethical questions about its use, patient’s autonomy as in most of the time the patient and surrogates are overwhelmed with the critical condition the patient is presenting with, and the details about this new technology. How do we ensure the patient’s beneficence? Is the new condition acceptable by the patient or not? Is the goal the quantity or the quality of life (8)? What is the psychologic status of the patient? Will he or she accept having this metallic pump inside his or her body ticking all the time? Will he or she be able to handle care of the LVAD (as changing batteries, taking care of LVAD drive to avoid infection, anticoagulation with its complications and regular blood tests and regular follow-up with the LVAD medical team?