Ethical issues surrounding mechanical circulatory support.

Abstract

Recent innovations in mechanical circulatory support (MCS) have significantly increased survival for patients with cardiac and respiratory failure. The introduction ofMCS into patient care has profoundly changed the management of heart failure and other previously fatal medical conditions. Among other devices, MCS therapies include ventricular assist devices (VAD), total artificial hearts, and extracorporeal membrane oxygenation (ECMO). Due to the quality of life implications associated with these devices, many ethical issues arise that providers must face when treating patients with MCS. Here we outline the ethical considerations physicians should understand while offering and managing MCS. The initial conversationwhen approaching patients regardingMCS should include an ethical process of informed consent, planned surrogate involvement for possible future decision-making, and clarification of bridge versus destination therapy. We discuss why routine palliative care involvement is recommended in the management of MCS patients. We examine how MCS impacts patients, families, caregivers, and clinicians, including physicians, respiratory therapists, and nurses. We also discuss ethical dilemmas that arise with the use of emergency MCS. In addition, deactivation of MCS is an ethically challenging process. Lastly, we discuss specific considerations for the use of MCS in pediatric patients. As MCS is a resource-intensive and invasive therapy with significant risks, physicians should be educated and aware of the ethical issues surrounding it.