Pro: LVAD: patient's desire for termination of VAD therapy should be challenged.

S VENTRICULAR ASSIST DEVICE (VAD) therapy for end-stage heart failure has become more prominent in the past decade, so have the psychosocial aspects of device management when patients face the end of life. A case is briefly presented to demonstrate the conflicting elements. The mechanical, emotional and ethical decision-making processes for management are discussed herein. The balance among patients’ desires, resource utilization, caretakers’ responsibilities, healthcare team, and physician obligation, is multifactorial and complex. The argument is espoused that a patient’s desire to terminate LVAD therapy, singularly, and taken in the context of the above-mentioned factors, necessarily should be challenged. CASE A 76-year-old Caucasian male physician with no previous cardiac intervention was admitted with a large anterior wall myocardial infarction and shock. After intubation in the emergency ward, he was urgently taken to the cardiac catheter lab where he received an LAD stent. He was further supported in the intensive care unit (ICU) with an intraaortic balloon pump (IABP) and intravenous inotropes. Consultation with the VAD program was obtained, and discussion with the family (including a physician son) was undertaken. He was not deemed medically fit for destination therapy (DT) yet, but consideration was proffered for a VAD at a future date if and when the patient recovered from the acute insult. The goal was to allow the patient to make informed decisions. The patient recovered and, after discussion, was discharged home in 10 days. He returned 1 week later and was in Class IV heart failure requiring inotropic therapy but no intubation. Further discussion ensued, and the patient agreed to a DT VAD. A HeartMate II VAD (Thoratec Corp, Pleasanton, California) was implanted, and although surgery was uneventful, the patient had complications of pneumonia, grade 4 sacral decubitus, fecal incontinence, swallowing difficulty (requiring tube feeds), and psychiatrically diagnosed clinical depression. On postoperative day 14, the patient requested the VAD to be turned off and given comfort measures only. Ventricular device therapy (VAD), begun as a bridge-totransplant intention, has climbed to new horizons as “destination therapy.” This nomenclature was adopted as device therapy became the endpoint of treatment for patients with end-stage heart failure for whom heart transplantation was not an option. In the approval of devices by the FDA for destination therapy (DT), major concerns were survival, morbidity, and durability. Along with these highly important parameters, the studies also incorporated quality-of-life (QOL) issues. The major data collection and reporting agency, the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS), has emphasized the importance of QOL measures in the long-term evaluation of VADs. 1 Nonetheless, reported 2-year survival for DT patients is between 58% and 74%. 2,3 Of importance in the management of patients with VADs for DT is the fact that these patients are managed by the VAD team from diagnosis to demise. Along with a palliative care discussion, there usually is an informal contract into which the patient and the VAD team enter, regarding care and responsibilities of each party for satisfactory outcomes for both. In particular instances, patients can and have requested termination of VAD therapy for various issues, including those unrelated to VAD. This position paper posits that patients’ desire to terminate VAD therapy should be challenged, particularly during the initial postoperative phase, and subjected to rigorous review. It is well documented throughout the literature that many patients suffer from postoperative feelings of helplessness, hopelessness, and depression, which can greatly affect their desire to live. Ultimately, all patients have a right over their own physical state, but herein are discussed the views from the VAD team caregivers.