Con: Patient's desire for termination of destination LVAD therapy should be respected.

ATIENT AUTONOMY is a fundamental principle of the medical decision-making process. Any competent patient who makes a rational decision to discontinue any form of medical or surgical therapy should be allowed to do so. The treating physician has a responsibility to make sure the patient understands the likely outcomes when medical therapy is withdrawn, but the decision to withdraw ultimately lies with the patient. A competent patient best understands his or her values, and the paradigm of shared decision-making recognizes the need to respect autonomy based on this principle. Principles of informed consent and patient autonomy have been upheld in American law for decades. In 1914, in a ruling on a case in which a patient was subjected to an operation without giving consent, Justice Benjamin Cardozo wrote, “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” 1 In 1990, the U.S. Congress passed the Patient Self-Determination Act, which required health care institutions to give patients written notice of their healthcare rights. 2 All patients were expressly given the right to facilitate their own healthcare decisions as well as the right to accept or refuse medical treatment. There is no conceivable situation in which a patient who has a destination LVAD should be denied these fundamental rights. If patients decide that their quality of life after implantation of an LVAD is worse than what they reasonably expected to have and that therefore they would like the LVAD to be removed, that decision should be respected. Decisions to withhold or withdraw medical therapies due to low quality of life are made every day in many situations throughout all fields of healthcare. The withdrawal of ventilatory support in a patient with refractory septic shock in a critical care unit, the disabling of an implantable cardioverter-defibrillator in a patient with advanced congestive heart failure in an outpatient cardiology clinic, or the discontinuation of cancer chemotherapy due to side effects are all reasonable in the right clinical situation if consistent with the patient’s goals. It should be no different for a patient who at one time chooses to be the recipient of a destination LVAD but thereafter changes his or her mind based on changing circumstances. A patient’s goals and values frequently change during the course of their medical treatment, especially with life-altering therapies such as left ventricular assist devices. In any scenario in which a patient expresses desire to withdraw medical therapy, these fundamental questions must be asked: What is the goal of the therapy? What is the likely outcome of the therapy? Are these goals and outcomes consistent with the patient’s values and goals? From a clinician’s perspective, the discussion with the patient may be quite different if the goals are palliation and symptom improvement versus simply living longer. Care also must be taken to make sure the patient understands, in a very specific way, what reasonably can be expected to happen once that therapy is discontinued. At the same time, however, the clinician should not be allowed to continually question a patient’s values and goals in an attempt to “break them down.” A patient who has made a reasoned decision must not be subjected to badgering by a physician. Clinicians must be cognizant of their own interests, which might compete with patients’ values and goals. Surgeons may be concerned that a poor outcome might reflect on their record, whether in formal reporting or simply in the eyes of referring physicians. Clinicians may consider withdrawal to be a failure on their part, or hold certain religious or cultural beliefs about withdrawal of therapies. However, the standard of care in American medicine is patient autonomy, and even in a patient who lacks decision-making capacity, substituted judgment takes precedence over what clinicians may perceive to be a patient’s best interest. The seminal REMATCH trial showed that patients with advanced heart failure who were randomized to destination LVAD therapy lived longer and had a better quality of life than those randomized to standard medical therapy. 3 Data from more recent studies and the recent INTERMACS report continue to show success with DT LVAD therapy in improving quality of life. 4,5 However, these same studies showed that a significant number of patients suffer major complications such as stroke, significant bleeding, permanent renal failure, and infection. Device thrombosis, infection, and failure often necessitate another operation for device replacement. Patients who experience a serious complication or device malfunction that leads to decreased quality of life should have the right to discontinue their LVAD if they so choose. In most cases, LVAD discontinuation involves deactivation of the device usually followed shortly by death (except in cases of ventricular recovery). LVAD deactivation is, therefore, a terminal event, to be accompanied by appropriate sedation, and can be similar to discontinuation of mechanical ventilation. Furthermore, as LVAD technology improves and becomes more widely disseminated, elderly patients and those with more comorbidities are increasingly likely to become LVAD candidates. Many of these patients will live long enough to develop other diseases such as cancer and dementia. If a patient’s quality of life suffers from a new disease unrelated to their LVAD, they should have the same opportunities as others