Ethical Dilemma of Elective VAD Deactivation: A Case Report

Abstract

<h3>Introduction</h3> Ventricular assist devices (VAD) are used to improve quality of life (QoL) however there are limited reports of VAD deactivation in patients who do not perceive an improvement to QoL despite medical stability. We present a case of an elective VAD deactivation in an otherwise medically stable patient in which QoL was not consistent with his wishes. <h3>Case Report</h3> Patient is a 77 year old male with long standing heart failure presented in cardiogenic shock requiring temporary VAD (Impella 5.5, Abiomed, Danvers, MA). He was stabilized, engaged with family, met VAD ambassador and consented for device (HeartMate 3, Abbott, Chicago, IL). Shortly after implant discharged to acute rehab and later began outpatient rehab. Patient developed suicidal ideation/plan due to poor QoL secondary to lumbar pain prompting involuntary admission. Discharged after psychiatry clearance with plan for epidural injection. Post injection, developed dyspnea and edema. Echo with new RV dilation and worsening AI. Patient required temporary inotropic support which was eventually weaned off. At this time patient wanted to deactivate VAD citing RV failure and lifestyle changes. Though euvolemic on oral diuretics, he requested hospice consult as QoL did not meet his expectation. Psychiatric evaluation as well as bioethics deemed appropriate capacity. Family meetings were held with the care team regarding his clinical improvement, but remained adamant and affirmed his decision. VAD deactivated 5 months post implant. <h3>Summary</h3> VAD deactivation typically follows severe complications, familial vs patient consent, or end of life scenarios. This case highlights the ethical challenge when a patient wishes to withdraw VAD in the setting of medical stability disproportionate to their perceived QoL. The principles of autonomy, informed consent, and nonmaleficence are evaluated in the setting of deactivation. With established capacity, the question arises from the VAD team at what point respecting autonomy borders euthanasia. Informed consent is obtained prior to VAD implant including the risks/benefits of therapy. Nonmaleficence speaks to providing no harm whereas VAD deactivation, where death is certain, creates a conflict, particularly when it is due to QoL perception. Mental health assessments should carry significance in the VAD evaluation workup to reduce the instances of QoL dissatisfaction.