Abstract
Significant strides have been made in the durability, portability, and safety of mechanical circulatory support devices (MCS). Although transplant is considered the standard treatment for advanced heart failure, limits in organ availability leave a much larger pool of recipients in need versus donors. MCS is used as bridge to transplantation and as destination therapy (DT) for patients who will have MCS as their final invasive therapy with transplant not being an option. Despite improvements in quality of life (QOL) and survival, defining the optimal candidate for DT may raise questions regarding the economics of this approach as well as ethical concerns regarding just distribution of goods and services. This paper highlights some of the key ethical issues related to justice and the costs of life-prolonging therapies with respect to resource allocations. Available literature, current debates, and future directions are discussed herein.
Highlights
While data suggest candidates who are Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profile 3 through 6 may benefit most from destination therapy (DT) [7], an inherent pressure to offer DT to sicker (INTERMACS Profile 1-2) patients may be governed by what Norman Daniels has termed as the rule of rescue
While the consideration of A4R with transplantation was made within the context of a single-payer, socialized system (Canada) this begs the question if such an approach is applicable beyond transplant and if A4R may be applied to DT
Improvement in the technology, as well as increasingly favorable costeffective analysis, suggests that DT may be a viable option for many patients with heart failure who are not transplanteligible
Summary
Heart failure is a serious and costly health care issue globally. The prevalence of heart failure in the US is 5.7 million patients, with 670,000 new cases diagnosed annually and greater than 56,000 deaths attributable to it. While the costs of DT have improved [2], as have survival and quality of life (QOL) [3], questions remain regarding how broadly DT should be utilized in the elderly, and there is a need for guidance regarding age and appropriate patient selection [4]. There remain great opportunities and challenges to caring for an ever-aging global population. We believe these points warrant emphasis and further consideration beyond cost effectiveness or survival analyses alone. In an era of rising healthcare costs, finite resources, and aging of the population, optimizing selection of patients for MCS and DT becomes increasingly important
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