Ethical Challenges With Deactivation of Durable Mechanical Circulatory Support at the End of Life: Left Ventricular Assist Devices and Total Artificial Hearts
Ethical Challenges With Deactivation of Durable Mechanical Circulatory Support at the End of Life: Left Ventricular Assist Devices and Total Artificial Hearts
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DOI：
10.1177/0885066611432415
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发表时间：
2014-01-01
影响因子：
3.1
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中科院分区：
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左心室辅助装置（LVAD）和全人工心脏（TAH）通过手术植入作为不可恢复心力衰竭的永久治疗。LVAD和TAH都是耐用的机械循环支持（MCS）器械，可以延长患者生存时间，但也可以改变生命结束轨迹。停止辅助循环的允许性存在争议，因为器械停用是一种终止生命的干预措施。耐用MCS旨在成功替代心脏病患者的天然生理功能。我们认为，新的致死性病理生理学（即，导致死亡的异常生理过程的自我延续级联）的存在是评估LVAD或TAH失活允许性的核心要素。当发生与LVAD或TAH替代的生理功能无关的新的致死性病理生理学时，永久性MCS的突然停药等同于允许自然死亡。这种致命病症的实例包括不可逆昏迷、循环性休克、压倒性感染、多器官衰竭、难治性缺氧或灾难性装置故障。在所有其他情况下，停用LVAD/TAH本身就是致命的病理生理学和死亡的近因。我们假设，新的致死性病理生理学的发生是判断持久MCS终止生命的中止是否允许的决定性因素。
Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) are surgically implanted as permanent treatment of unrecoverable heart failure. Both LVADs and TAHs are durable mechanical circulatory support (MCS) devices that can prolong patient survival but also alter end-of-life trajectory. The permissibility of discontinuing assisted circulation is controversial because device deactivation is a life-ending intervention. Durable MCS is intended to successfully replace native physiological functions in heart disease. We posit that the presence of new lethal pathophysiology (ie, a self-perpetuating cascade of abnormal physiological processes causing death) is a central element in evaluating the permissibility of deactivating an LVAD or a TAH. Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions replaced by an LVAD or a TAH. Examples of such lethal conditions include irreversible coma, circulatory shock, overwhelming infections, multiple organ failure, refractory hypoxia, or catastrophic device failure. In all other situations, deactivating the LVAD/TAH is itself the lethal pathophysiology and the proximate cause of death. We postulate that the onset of new lethal pathophysiology is the determinant factor in judging the permissibility of the life-ending discontinuation of a durable MCS.