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Hospice and Palliative Medicine
Henry Ford Hospital
Objectives: 1)Describe an approach to assessing capacity for end-of-life decision making in apatient with depression 2)Recognize the Interdisciplinary Team’s (IDT)approach to navigating a patient’s request to discontinue a Left Ventricular Assist Device (LVAD) 3)Define the ethical principles that are involved inthedecision to withdraw LVAD therapy. Background: There is ethical consensus that patients with capacity have the right to stopany life-extendingmedical treatment, includingan LVAD. When a patient with depression requests discontinuation ofan LVAD, capacity for decision-making can be called into question, particularly when there has been inconsistency in expressed wishes. An Interdisciplinary approach is needed to navigate these decisions. Case: A 62year-old man had a stroke one month after LVAD implantation, resulting in hemiparesis,dependence for his basic needs, and need for transition to a nursing facility. During an admission two years later,he expressed that his quality of life was poor and he wanted to terminate his LVAD. He was found to be depressed and grieving an unexpected loss. He accepted treatment for depression and agreed with continuing LVAD therapy. Two months later, he reported that while life at the nursing facility was “not Disney World,” his quality of life was acceptable. Two weeks later, he returned to the hospital requesting LVAD termination. He acknowledged depressed mood, but felt I t stemmed entirely from his dependence on othersandwould never improve. His wife supported his decision and felt it was consistent with his long-standing values. Behavioral health, palliative care, ethics, and the heart failure team were involved. Although there was some evidence of fluctuation in his wishes over time,team consensus was that he had decision-making capacity and his request to discontinue the LVAD should be honored. Conclusion: Although extension of lifeis often seenas a benefit, we respected the autonomy of this patient to determinethat his quality of life was unacceptable and continuing life-extending treatment was not a benefit in his view. Depression was present but given the persistence of the patient’s request, clear rationale for his decision, and support from his wife, we respected his choice.
Nagaraj, Suchi; Chasteen, Kristin; Bryce, Kelly; and Smith, Karen, "Navigating a Request for LVAD Termination in the Context of Depression" (2019). Case Reports. 41.