The use of advance directives among patients with left ventricular assist devices

Patients who undergo implantation of left ventricular assist devices (LVADs) often have improved quality of life, but may eventually succumb to their heart failure and/or sustain LVAD-related complications. In end-of-life situations, decisions must be made about when to deactivate LVAD support. Previous studies have demonstrated that end-of-life planning, particularly with the use of advance directives (ADs), can clarify patients' end-of-life preferences when they are unable to speak for themselves. However, many patients do not have ADs, and among patients who do, the ADs may lack useful information on how to guide care surrogates and clinicians regarding patients' preferences on life-sustaining treatments. The authors retrospectively reviewed the charts of 68 patients with advanced heart failure (56 men [82%]; mean [standard deviation] age, 59.0 ± 12.2 years) who underwent LVAD implantation between March 2003 and January 2009. The indication for the LVAD was destination therapy in 36 (53%) patients and bridge to heart transplant in 32 (47%) patients. Overall, 32 (47%) patients had ADs of varying types; 25 (78%) ADs were completed before LVAD implantation. Although life-sustaining treatments (eg, tube feeding, cardiopulmonary resuscitation, mechanical ventilation, and hemodialysis) were mentioned, none explicitly mentioned the LVAD or withdrawal of LVAD support at the end of life. We hypothesize that if instructions regarding LVAD management in ADs are explicit, surrogate and clinician distress may decrease, and ethical dilemmas may be avoided.