New guideline on mechanical circulatory support tackles device selection, ethical dilemmas and more

“This guideline is the first of its kind providing evidence-based recommendations dedicated to the growing field of acute MCS combining indications, peri-implant considerations, and post operative care for patients with heart and lung failure and will serve as the basis for further research and discussions in the field,” added project lead Alexander Bernhardt, MD, project lead on the guideline and surgical director of the heart transplantation and mechanical circulatory support program at University Heart and Vascular Center Hamburg in Germany. “The inclusion of interdisciplinary and interprofessional aspects of acute MCS treatment highlights modern team-based approaches in medicine.”

Withdrawal of acute MCS: When should it be considered? What if the patient requests it?

One of the key topics included in the new guideline is the ethics of discontinuing MCS. These devices are used for very specific reasons; if plans change, due to the patient’s worsening health or another factor altogether, it is important to reassess that patient’s situation.

“If support was initiated for the purpose of bridging therapy to transplant, or durable ventricular assist device (VAD), and that is no longer an option, then the decision to discontinue therapy should be made on clinical criteria,” the authors wrote. “This is not a patient or surrogate decision. Although the decision should be made with input from family, surrogate decision makers, palliative care, and VAD coordinators, continued support on acute MCS without an endpoint should be avoided. For some people, discussion about withdrawal of support or end-of-life decisions is viewed as disrespectful. In these settings, use of structured interview tools might help clinicians.”

The guideline also explores the complexity of these scenarios. Physicians often want to “retain decisional authority,” for example, but shared decision-making urges physicians to work together with patients when considering crucial next steps. This may lead to times when veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is not used at all for a severely ill patient or other times when VA-ECMO is stopped due to a “chronically ill patient's desire to avoid further suffering.”

The authors emphasized it is ethically acceptable to discontinue acute MCS at the rest of a patient or patient surrogate. However, they added, clinicians should make sure these decisions aren’t made in moments when a patient is especially depressed; identifying the symptoms of depression can go a long way toward ensuring these discussions happen at the right time.

“Patients’ rights to self-determination and autonomy should also extend to a respect for their religious beliefs and practices,” the authors wrote. “Given the penetration of these technologies, implantation of acute devices will occur in patients of many religious faiths which may have clearly expressed directives on how to consider discontinuation; however, there is also confusion as to what a particular religious faith might expect. Many religions support withdrawal of support if the patient finds the medical situation to be burdensome. Involvement of a religious leader of the same faith (such as a priest, imam, rabbi or elder) can be useful in understanding choices regarding end-of-life decisions.”

There are legal protections in United States and much of Europe for clinicians facing these difficult scenarios. The authors did add that this may not be the case in other parts of the world.

Read the full joint guideline in the Journal of Cardiac Failure here or in the Journal of Heart and Lung Transplantation here.