LVAD & New Medical Ethics

[Kanastrous]

WASHINGTON - After bypass surgery and two heart attacks, the 62-year-old's heart was failing. Desperate, he grasped at his last hope: a surgically implanted heart pump. But following infections, kidney failure and other complications, along with months in the hospital, he returned home weaker than ever.

"He now sleeps a great deal, eats poorly, walks little and needs help to go to the bathroom. He also complains of significant pain," Jeremy R. Simon, a bioethicist at Columbia University, wrote recently in a medical ethics journal. "He understands that he will likely die within hours after the device is turned off, but he no longer wishes to live in his current state."

The man's request to shut off the pump, however, made Simon, who serves on the ethics committee at New York-Presbyterian Hospital, uncomfortable. Turning it off would be "tantamount to removing the patient's heart," he wrote, changing some details to protect the patient's privacy. "Medicine has no role in such cases."

Such cases, while unusual, are occurring more frequently as the rapidly rising number of elderly Americans is making heart failure more common and fueling demand for partial artificial hearts. Although most requests to discontinue the devices are honored, some patients have been found dead alone at home with their pumps powered off, raising fears that they may have taken matters into their own hands.

The debate illustrates how new medical technologies often proliferate before society has resolved the issues they raise, such as what to do when a patient has had enough. Similar clashes have arisen over pacemakers and implanted defibrillators, and experts say such predicaments will multiply as researchers rush to develop a host of other replacement organs.

"Anytime you create new forms of life support, you create the possibility for new ethical dilemmas," said Katrina A. Bramstedt, a bioethicist at the California Pacific Medical Center in San Francisco.

The latest quandary centers on left ventricular assist devices (LVADs), which are implanted near the heart and attached to one of the main pumping chambers and the aorta, the main artery supplying blood to the body.

After decades of disappointing attempts to create fully implantable artificial hearts, LVADs emerged as an intermediate crutch to keep transplant candidates alive long enough to get a donated organ. But after researchers discovered that the devices could significantly improve a patient's quality of life, doctors began using them as "destination" therapy, meaning patients would live with them for years with no expectation of a transplant.

"It's a new field," said Soon J. Park, director of the LVAD program at the Mayo Clinic in Rochester, Minn. "There are plenty of people who are sick out there who would benefit from this."

Surgeons at more than 60 centers in the United States are now implanting at least 1,000 LVADs each year. Smaller, more durable and more easily implanted versions are being developed, including one that was approved just this week. With at least 5 million Americans suffering from heart failure, 550,000 new cases being diagnosed each year, only about 2,000 hearts available for transplant each year, and Medicare willing to pay for LVADs (at a typical cost of $200,000), experts predict the number will soar.

"We are at the cusp of a rapid expansion of this type of therapy," said Park, who estimates that within the next five years, 10,000 Americans annually may get the pumps.

The devices are lifesavers for many. They keep some patients alive long enough to get a transplant; maintain others until their hearts heal from surgery, infections or other complications; and sustain a growing pool of people hoping to have a few more decent years.

"I was in pretty bad shape before this," said Clarence Horton, 64, of Edgewater Park, N.J., who recently received an LVAD. "I was very short of breath. I couldn't move around. I was on my way out. Now I feel 200 percent better."

Recipients, however, are prone to complications, including infections from the power line that protrudes from the skin, as well as strokes caused by clots that can form in the pumps. As more patients receive the devices, inevitably the risks outweigh the benefits for some, or the benefits are overtaken by complications.

"The hardest thing to grapple with is these patients often are not asking for relief from any acute distress, per se, but are asking for relief from the burdens of a life dependent on an artificial technology," said Scott D. Halpern, a bioethicist at the University of Pennsylvania. In some cases, patients wake up to discover that an LVAD has been implanted in an emergency.

Said Mary Lou O'Hara, who coordinates LVAD care for the University of Pennsylvania Health System: "Some patients go into this with their eyes wide open and others have an acute event and wake up with the device. It can be very challenging for individuals who don't have the coping skills to deal with it."

Most doctors and bioethicists equate the devices to ventilators, feeding tubes and other forms of life support that patients or their families have the right to discontinue if they believe they are fruitless or if their quality of life deteriorates.

"We need to respect the free will and autonomy of patients," said Timothy W. Kirk, a bioethicist at Villanova University. "It is not assisted suicide or euthanasia, because what's killing them is the underlying disease."

The devices are discontinued only after patients are evaluated emotionally and physically, all alternatives have been explored, and ethicists and family members are consulted, experts say.

"You want to rule out the idea that they are acutely depressed or there is an acute event that right now makes life look pretty grim but that they may get past," said Michael Petty, a nurse who works with LVAD patients at the University of Minnesota Medical Center, Fairview.

While agreeing that patients can decide to discontinue their LVADs, some say that the devices raise unique issues.

"This is unlike anything else we deactivate," said James Kirkpatrick, a cardiologist and ethicist at the University of Pennsylvania. "When you turn off an LVAD, it can make the person worse. You can basically worsen the heart function. So you're not just stopping something and letting nature take its course. You're actually doing harm, potentially."

But Simon and others go further, arguing that the technology represents something entirely different from other forms of life support.

"Once a patient leaves the hospital, the LVAD ceases to be a medical treatment and becomes effectively part of the patient himself, much like a transplanted organ or even a native one," Simon wrote in the January-February issue of the Hastings Center Report, which is published by the Hastings Center, a bioethics think tank. "We would not remove a patient's biological heart, transplanted or native, simply because the patient was suffering greatly from heart failure and did not want to go on; nor should we disable his LVAD."

Simon declined to reveal additional details about the patient he dubbed "Mr. P," but he said Mr. P could turn off the device himself or let the batteries run out.

"Mr. P is presumably uncomfortable with the options because they seem to him like suicide," Simon wrote. "The fact that the patient does not want to take action on his own, however, does not authorize others to hasten his death for him."

Others are also uneasy.

"Our normal intuition is that it's illegal and probably immoral to actively kill someone," said Robert M. Veatch, a Georgetown University bioethicist. "If you think about stopping the left ventricular assist device as something like stopping the heart, then you have to deal with the possibility that this is an active killing."

One partial solution would be for doctors to avoid implanting the devices in those who are too old or too sick.

"There's definitely some patients who have LVADs who should not have received them," said Bramstedt, the bioethicist at the California Pacific Medical Center. "Sometimes when you put these in, the patient actually gets worse. And now they are in limbo, hooked up to this machinery."

Surgeons who implant the devices argue that doctors are getting better at choosing recipients.

"Our first mission as physicians is to do no harm," said Robert L. Kormos, director of the Artificial Heart Program at the University of Pittsburgh Medical Center.

In the meantime, more doctors are discussing the possibility of turning off the devices so patients know that palliative care is available, and doctors and family know what the patient would want if they become incapacitated and further care is futile.

Still, patients have been found with the devices detached from the power source, raising the possibility that they disconnected them without thinking that doctors could help them die.

Said Rodney Tucker, medical director of the palliative care center at the University of Alabama at Birmingham: "I don't think we've seen the full spectrum of how we'll deal with these devices in the long-term. The technology is still in its infancy. Whenever you have technology in its infancy, that technology will inevitably have some falls."

http://www.msnbc.msn.com/id/24287496/

[lordofFNORD]

These cases point out a problem with current medical ethics, the arbitrary difference between withholding life-saving care and assisting suicide. Dead is dead. Then this silly argument over whether this is equivalent to stopping the heart would be academic.

I've always thought that it's cruel that an incapacitated patient who doesn't want to live is condemned to starvation/dehydration, instead of a painless, assisted death.

Denying food and water to an unwanted pet to kill it is animal cruelty; denying food and water to a condemned prisoner is torture. But for a innocent and terminally ill or incapacitated patient, denying food and water is the only "ethical" option.

[Kanastrous]

That's a problem for cryonicists, too (whatever you may think of cryonics...)

If you want to avoid autopsy, which doesn't leave much of anything to freeze, you sometimes have to starve to death, in order to avoid it.

[CmdrWilkens]

These cases point out a problem with current medical ethics, the arbitrary difference between withholding life-saving care and assisting suicide. Dead is dead. Then this silly argument over whether this is equivalent to stopping the heart would be academic.

Its not some arbitrary distinction but rather a real, and oft debated, ethical difference. If I shot someone then I have killed them, if I don't hit the shooter with a baseball bat I've let them be killed but am I ethically guilty of murder? There is a distinction between not intervening and actively partaking in a person's life and the two are NOT and CANNOT be equal. Just as we distinguish between the guilt of a person who intended to kill someone and a person who killed another by accident thre is a distinction between these two points. Dead may be dead but the means by which we get there speaks very much to the moral condition of those around us. Actively helping death is different from failing to intervene. It may still be cold and heartless to some degree but it comes down to the difference between the scenario as it is and how it would play out without the actor there. In the case of assisted suicide if the doctor is not there then it is an even likelyhood that the person will not be able to kill themselves and will remain alive. In the case of witholding care if the doctor is not there the person will die. That is the distinction.

[lordofFNORD]

Its not some arbitrary distinction but rather a real, and oft debated, ethical difference.

I'll admit, arbitrary overstates the case. But the current state of medical ethics creates more problems than it solves, by making a hard line on assisted suicide.

If I shot someone then I have killed them, if I don't hit the shooter with a baseball bat I've let them be killed but am I ethically guilty of murder?

That's a false analogy on multiple levels, most notably that the victim did not consent to die in that case.

There is a distinction between not intervening and actively partaking in a person's life and the two are NOT and CANNOT be equal.

Agreed, most notably in the matter of aiding/harming a nonconsenting subject.

In the case of assisted suicide if the doctor is not there then it is an even likelyhood that the person will not be able to kill themselves and will remain alive. In the case of witholding care if the doctor is not there the person will die. That is the distinction.

That's not true in many case, particularly the cases dealt with here. In most cases where withholding care would kill someone, doctors could kill them more quickly if they were allowed to. That's one immediate change that would relieve suffering, with no other effect on medical practice:

Current practice:
If a patient requires medical care to survive and consents, then it is ethical to withhold care.
[and by consents, we include is of sound mind, discusses with doctor, etc.]

New practice:
If a patient requires medical care to survive and consents, then it is ethical to withhold care and/or administer a lethal but painless dose of chemicals.

That much, at least, is undeniably a sensible and humane change. Admittedly it does not deal with the problem listed above, defining whether medical care includes already implanted, self-contained devices. I would propose:

If a patient is dissatisfied with their current physical state of health, and foreseeable improvement is highly unlikely (we can include a p-value if we want to get really technical, but I'm not sure what it is), and consents, then it is ethical to withhold care and/or administer a lethal but painless dose of chemicals.

I'd probably require somewhat more counseling, along with a waiting period, in the consent.

[CmdrWilkens]

If I shot someone then I have killed them, if I don't hit the shooter with a baseball bat I've let them be killed but am I ethically guilty of murder?

That's a false analogy on multiple levels, most notably that the victim did not consent to die in that case.

The victim didn't consent in EITHER case. I'm not talking about suicide here I'm talking about if I took a gun walked out on the street and shot the next person I saw that would be murder. If I walked out with a baseball bat, saw someone about to shoot another and failed to act then I carry some burden (though not as much due to risk of personal harm that makes self preservation kick up). The point I was making is that in both cases a person died. In the former case I was an active agent, in the later case i was a passive agent which allowed another active agent to act when I had the possibility of stopping that agent.

In the case of assisted suicide if the doctor is not there then it is an even likelyhood that the person will not be able to kill themselves and will remain alive. In the case of witholding care if the doctor is not there the person will die. That is the distinction.

That's not true in many case, particularly the cases dealt with here. In most cases where withholding care would kill someone, doctors could kill them more quickly if they were allowed to. That's one immediate change that would relieve suffering, with no other effect on medical practice:

Current practice:
If a patient requires medical care to survive and consents, then it is ethical to withhold care.
[and by consents, we include is of sound mind, discusses with doctor, etc.]

New practice:
If a patient requires medical care to survive and consents, then it is ethical to withhold care and/or administer a lethal but painless dose of chemicals.

That much, at least, is undeniably a sensible and humane change. Admittedly it does not deal with the problem listed above, defining whether medical care includes already implanted, self-contained devices. I would propose:

If a patient is dissatisfied with their current physical state of health, and foreseeable improvement is highly unlikely (we can include a p-value if we want to get really technical, but I'm not sure what it is), and consents, then it is ethical to withhold care and/or administer a lethal but painless dose of chemicals.

I'd probably require somewhat more counseling, along with a waiting period, in the consent.

I don't think your idea is wrong but what it doesn't do is address what difference, if any, there is between being an active agent in ending a person's life (administering a lethal dosage) or being a passive agent while another active agent (the disease) acts on the person while you have the ability to intervene.

I'm not going for universal applicaiton here but my point is that there is an ethical distinction between being an active or a passive agent and as such I understand WHY current medical practice makes this distinction. Now that being said if we look at this in a purely Utilitarian light the matter comes down to how the harm of a person dying by virtue of lack of life-saving care versus being put to sleep for all intents and purposes compares against the doctor's additional burden in the case of being an active versus passive agent.

[lordofFNORD]

The victim didn't consent in EITHER case.

I meant a false analogy to the medical ethics case, where patients do consent to die. I recognize that it may be ethical in some cases to withhold care even to patients who don't want to die, but it is never ethical to kill them.

I don't think your idea is wrong but what it doesn't do is address what difference, if any, there is between being an active agent in ending a person's life (administering a lethal dosage) or being a passive agent while another active agent (the disease) acts on the person while you have the ability to intervene.
-snip-
I understand WHY current medical practice makes this distinction.

That is correct, as such I also recognize why ethics is the way it is. I just don't think that difference is relevant when patients give informed consent to die, and as such current medical ethics is wrong.

[Knife]

Its not some arbitrary distinction but rather a real, and oft debated, ethical difference. If I shot someone then I have killed them, if I don't hit the shooter with a baseball bat I've let them be killed but am I ethically guilty of murder?

The easy answer is motive or in this case intent. Everyone in the state the op is in is on barrowed time anyways. Those in the health care field know that, and the problem lies with those outside the staff providing them with care.

There is a distinction between not intervening and actively partaking in a person's life and the two are NOT and CANNOT be equal.

You are discounting those that interven and partake in a persons life and yet realized they will die. In military terms, no one blames the field medic when they can't stop a grunt from bleeding out after a gunshot.

Just as we distinguish between the guilt of a person who intended to kill someone and a person who killed another by accident thre is a distinction between these two points.

You're oversimplifing things. There are more than two positions, speaking as a former Marine grunt and a current Nursing student.

Dead may be dead but the means by which we get there speaks very much to the moral condition of those around us.

Explain? Going to die and going to die a little longer are the same thing with in reason.

Actively helping death is different from failing to intervene. It may still be cold and heartless to some degree but it comes down to the difference between the scenario as it is and how it would play out without the actor there. In the case of assisted suicide if the doctor is not there then it is an even likelyhood that the person will not be able to kill themselves and will remain alive. In the case of witholding care if the doctor is not there the person will die. That is the distinction.

Disagree again. There are a lot of people perscriped morphine to 'ease' their pain which is tantamount to ease their passing. Sure, the morphine is to lessen the stressors so they can pass rather than actually make them pass, but what's the differnce?

Also, placing a patient on their left side, places slightly more stress on their heart than the right. Puting a patient who is already on their wayout a bit of an advantage.

[Boyish-Tigerlilly]

The issue of passive vs active euthanasia is a bit muddy, but I don't see in some cases a big ethical difference intrinsically between killing and letting die in at least SOME cases where the intention and end consequences are similar/the same.

The purpose of euthanasia, passive or active, is to bring about a good, painless death that maintains dignity and prevents suffering. Active can mean you do something deliberately, while passive can mean you deliberately forgo doing something or do not intervene in the first place.

If you withhold or remove care or aid, when such is known to be likely to hasten the death of or actually kill someone, in the context of euthanasia's purpose, it's a superficial difference compared to deliberately giving a pill you know will have the same effect, given it's consensual at least.

There was an interesting case study presented by Dr. Singer in Practical Ethics. Doctors were treating newborns suffering from a terminal disease. They could keep the baby alive, but the chances of it dying early in life were high. They didn't want to "kill" the baby outright, because it wasn't legal, so they decided to wait for a minor complication unrelated to the disease decided just not to treat it and let "nature take its course." Unsurprisingly, the baby died, and that was their intention. They just got something else to do it because they wanted to euthanize it and avoid paying to keep it alive when eventually it would die anyway.

The other option, not legal, was to actively, painlessly kill the child by giving it some injection or chemical. In both cases, the intention was to bring about death, and the intention was successfully implemented. They knew all along what they were doing and wanted it to happen. They could have prevented the death, but given it was a terminal case, they thought it best not to extend the life. It wouldn't be morally wrong either way itself. To deliberately hasten death is to deliberately hasten death. Inaction can lead to the same desired consequences.



There is some principle called "The Principle of Double Effect" but this is often used to allow people to prescribe medicines that they know will, in said dose, have the effect of killing them, but they claim that's only a side effect and that the primary effect is merely to alleviate pain.

[Boyish-Tigerlilly]

Edit:

It would be an interplay of:

1. Foreknowledge
2. Intention
3. Consequences (for the individual and what you might have to sacrifice)

That bring killing and letting die together morally.