Matters to address prior to introducing new life support technology in Japan: three serious ethical concerns related to the use of left ventricular assist devices as destination therapy and suggested policies to deal with them.
Matters to address prior to introducing new life support technology in Japan: three serious ethical concerns related to the use of left ventricular assist devices as destination therapy and suggested policies to deal with them.
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DOI：
10.1186/s12910-018-0251-z
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发表时间：
2018-02-27
影响因子：
2.7
通讯作者：
Kadooka Y
中科院分区：
文献类型：
--
作者：
Asai A;Masaki S;Okita T;Enzo A;Kadooka Y
目的治疗（DT）是在不适合心脏移植的终末期严重心力衰竭患者中永久植入左心室辅助装置（LVAD）。DT改善了终末期心力衰竭患者的生活质量和预后。然而，DT也有缺点，例如危及生命的并发症以及患者在发生此类重大并发症后可能超过其预期寿命。由于对死亡和生命神圣性的根深蒂固的文化和宗教信仰，日本社会可能还没有准备好做出必要的改变，使患者在某些情况下停用LVAD，以避免不必要的痛苦。基于尊重自主性和尊严而允许LVAD失活的西方伦理观点迄今尚未被日本接受，考虑到当前的日本文化和传统价值观，也不太可能被接受。一些医疗保健专业人员可能认为患者没有资格接受DT，除非他们已经准备好了预先指示。如果发生这种情况，编写预先指示的权利将变成这样做的义务。此外，DT的患者选择提出了另一个伦理问题。由于生命神圣的原则占主导地位，而医疗开支方面又缺乏成本意识，因此会忽略医学上适当的排除准则，而透过现场判断，对各种病人，包括高龄病人、失智症病人，什至持续植物人状态的病人，采用DT。日本迫切需要制定和颁布患者权利基本法。该法应包括：尊重病人的自决权;拒绝不想要的治疗的权利;准备具有法律约束力的预先指示的权利;拒绝准备这种指示的权利;以及获得国家保险的医疗保健。它应该使那些关心病人护理涉及DT寻求伦理委员会的道德意见。此外，还应声明，以适当方式参与生命支持中止的医疗保健专业人员不受任何法律的诉讼的影响，他们有权认真反对LVAD停用。
Destination therapy (DT) is the permanent implantation of a left ventricular assist device (LVAD) in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation.
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