Ann Thorac Surg 2002;73:1688
© 2002 The Society of Thoracic Surgeons
a Director of Clinical Ethics, Columbia-Presbyterian Medical Center, New York, NY, USA
b Cardiovascular Institute, Department of Surgery, Columbia Presbyterian Center, New York Presbyterian Hospital, MHB 7-435, 177 Fort Washington Ave, New York, NY 10032, USA
To the Editor
As more sophisticated innovations in medical technology enable us to intervene in cases of ever-sicker patients, ICU populations now consist of significant numbers of patients who can be kept alive but who have minimal chances of surviving to discharge. In our hospital, 3% of ICU patients stay more than 14 days, yet this cohort utilizes 25% of the beds annually. This group has a 50% in-hospital mortality with significantly increased mortality over the 2 years post discharge. Often an extended ICU course occurs despite physician judgment that intensive care will not enable the patient to leave the hospital alive, but will result in unnecessary suffering and prolong the dying process. Lack of understanding by patients or their families of the goals and reasonable possibilities of high-risk intervention is often a cause for conflicts and confusion when the issue of cessation of treatment is raised.
The Ethics Committee of the Columbia Presbyterian Center of The New York Presbyterian Hospital has drafted a statement that patients and physicians must review together prior to placement of a ventricular assist device (VAD) or, when circum
stances do not permit, immediately thereafter. The statement asserts that VAD restoration of hemodynamic stability in a patient with critical myocardial dysfunction may, for various reasons, not reach the goal of enabling the patient to receive a heart transplant or achieve adequate stability to be discharged home on the device.
The Ethics Committee drafted the statement and drew up a procedure for removing VADs after a number of cases in which removal was clearly medically warranted but was carried out without uniform guidelines, leaving both families of patients and their physicians uncomfortable and confused. The statement reads as follows:
"Every effort will be made to help our patients on ventricular assist devices (VAD) to improve to the point where they meet the criteria to receive a heart transplant, or stabilize enough to be discharged from the hospital on the VAD. However, if despite all our efforts, a patient has no reasonable chance of achieving either of these goals, we will discontinue the VAD, as it will, under these circumstances, no longer be serving the purpose for which it was originally used. When this occurs, the VAD will be discontinued only after the physicians caring for the patient are in agreement that the goals for VAD use cannot be met, and have consulted with the patient, or, when the patient is too ill, with the family or friends of the patient."
We believe such a document is needed at the beginning of the patients care to make clear to the family the goals of VAD use. Specifically, a VAD should not be used solely to prolong a patients dying. Once medical determination has been made by both the attending cardiac surgeon and the attending cardiologist that the patient cannot survive to leave the hospital, continued use of the VAD is inappropriate.
If the patient or his health care proxy or surrogates disagree with the decision to discontinue the VAD, the case is submitted to the ethics committee for arbitration.
Under current New York State case law, one cannot remove a patient who lacks decisional capacity from life support, even with the consent of surrogates, unless one of three criteria has been met:
We do not believe that these criteria were intended to apply to the unique circumstances presented by patients on VADs. A patient on a VAD is more akin to a patient on heart-lung bypass than to a patient who is receiving life support from a ventilator or from hemodialysis. Because of the complexity and resource-intensive nature of heart-lung bypass, the surgeons professional judgment is the sole criterion by which this form of life support is terminated in the OR. By contrast, patients on ventilator life support or on dialysis can often be stabilized and discharged from hospital. Accordingly the more conservative criteria for termination of life support can reasonably apply to them.
VAD support falls somewhere between heart-lung bypass and ventilator support. Hopelessly ill VAD patients, in whom device discontinuation is being considered, are almost always critically ill, highly complicated, and unstable patients who cannot be transferred out of the ICU for continued care. In terms of survivability to discharge, further VAD treatment in these patients would be futile, medically inappropriate, and extremely wasteful of limited resources. Furthermore, continued VAD treatment in the ICU of such patients could seriously undermine the fiscal integrity of the entire transplant and VAD program and thereby potentially harm patients who are in need of these sophisticated technologies.
In summary, the following procedure for removal of VAD devices has been adopted in our hospital:
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