Ethical Considerations in the Long-Term Ventricular Assist Device Patient

Purpose of Review: As the heart failure population continues to age, the need for definitive therapies such as ventricular assist devices (VADs) to extend life and alleviate suffering from end-stage disease directly increases. The goal of this article is to examine the ethical principles of autonomy, beneficence, non-maleficence, and justice within the context of long-term VAD patients. Recent Findings: Survival rates in VAD-implanted patients have improved in parallel with modernization of device design and surgical technique, reaching that of cardiac transplantation at 1 year post-procedure. Even the sickest patients, those once deemed transplant-ineligible, have been proven to benefit from device implantation and in some cases to a point of becoming eligible for cardiac transplantation. Nevertheless, VAD implantation remains a high-risk procedure with in-hospital mortality rates reaching up to 27% post-procedure and requires intensive upkeep even after successful implantation. Furthermore, end-of-life decisions are complicated by consideration of device deactivation in patients who may not die immediately from an otherwise lethal pathophysiology. Summary: Ethical considerations in selection of patients, goals of implantation, and length of therapy become important to preserve the efficacy of treatment and maximize resource utilization. Advanced directives, shared decision-making, and multi-disciplinary approach to treatment have been shown to improve outcomes with respect to both survival and quality of life.