Cai Amanda, Eisen Howard J
Department of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA.
Drexel University College of Medicine, Philadelphia, PA, USA.
Curr Heart Fail Rep. 2017 Feb;14(1):7-12. doi: 10.1007/s11897-017-0313-4.
As the heart failure population continues to age, the need for definitive therapies such as ventricular assist devices (VADs) to extend life and alleviate suffering from end-stage disease directly increases. The goal of this article is to examine the ethical principles of autonomy, beneficence, non-maleficence, and justice within the context of long-term VAD patients.
Survival rates in VAD-implanted patients have improved in parallel with modernization of device design and surgical technique, reaching that of cardiac transplantation at 1 year post-procedure. Even the sickest patients, those once deemed transplant-ineligible, have been proven to benefit from device implantation and in some cases to a point of becoming eligible for cardiac transplantation. Nevertheless, VAD implantation remains a high-risk procedure with in-hospital mortality rates reaching up to 27% post-procedure and requires intensive upkeep even after successful implantation. Furthermore, end-of-life decisions are complicated by consideration of device deactivation in patients who may not die immediately from an otherwise lethal pathophysiology. Ethical considerations in selection of patients, goals of implantation, and length of therapy become important to preserve the efficacy of treatment and maximize resource utilization. Advanced directives, shared decision-making, and multi-disciplinary approach to treatment have been shown to improve outcomes with respect to both survival and quality of life.
随着心力衰竭患者群体不断老龄化，对诸如心室辅助装置（VAD）等延长生命并直接缓解终末期疾病痛苦的确定性治疗方法的需求也在直接增加。本文的目的是在长期VAD患者的背景下审视自主、行善、不伤害和公正等伦理原则。
随着装置设计和手术技术的现代化，接受VAD植入患者的生存率有所提高，术后1年达到心脏移植的生存率。即使是病情最严重、曾经被认为不适合移植的患者，也已被证明能从装置植入中获益，在某些情况下甚至达到有资格接受心脏移植的程度。然而，VAD植入仍然是一项高风险手术，术后住院死亡率高达27%，即使成功植入后也需要密集维护。此外，对于那些可能不会因其他致命病理生理状况而立即死亡的患者，考虑停用装置会使临终决策变得复杂。在患者选择、植入目标和治疗时长方面的伦理考量对于维持治疗效果和最大化资源利用变得至关重要。预先指示、共同决策以及多学科治疗方法已被证明能在生存和生活质量方面改善结局。
