Destination left ventricular assist device and end-of-life: The role of palliative medicine

Left ventricular assist devices are being used as destination therapy for patients with chronic end-stage heart failure who are not candidates for heart transplantation because of advanced age or comorbidities. Compared with medical therapy, use of destination therapy viewed as a palliative therapy improves survival, quality of life and functional status in appropriately selected patients. However, the complications of left ventricular assist devices can adversely influence quality of life and alter the trajectory of end-of-life, raising certain ethical challenges (e.g. withdrawal of left ventricular assist devices support) that are likely to become more complex as care teams gain experience and we have more information about patients experiences. These ethical challenges ought to be adequately addressed in clinical practice as soon as possible, for preventing conflicts related to care management in patients engaged in the destination therapy program. In this article, we advocate early implication of palliative care specialists in a multidisciplinary care approach, patient and caregiver-centered, for anticipating device-related complications, end-of-life trajectories and timing of device deactivation, sometimes requested by the patients or their surrogate decision-makers. (C) 2013 Elsevier Masson SAS. All rights reserved.