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Heart Pump Creates Life-Death Ethical Dilemmas

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By Rob Stein
Washington Post Staff Writer
Thursday, April 24, 2008

After bypass surgery and two heart attacks, the 62-year-old's heart was failing. Desperate, he grasped at his last hope: a surgically implanted heart pump. But following infections, kidney failure and other complications, along with months in the hospital, he returned home weaker than ever.

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"He now sleeps a great deal, eats poorly, walks little and needs help to go to the bathroom. He also complains of significant pain," Jeremy R. Simon, a bioethicist at Columbia University, wrote recently in a medical ethics journal. "He understands that he will likely die within hours after the device is turned off, but he no longer wishes to live in his current state."

The man's request to shut off the pump, however, made Simon, who serves on the ethics committee at New York-Presbyterian Hospital, uncomfortable. Turning it off would be "tantamount to removing the patient's heart," he wrote, changing some details to protect the patient's privacy. "Medicine has no role in such cases."

Such cases, while unusual, are occurring more frequently as the rapidly rising number of elderly Americans is making heart failure more common and fueling demand for partial artificial hearts. Although most requests to discontinue the devices are honored, some patients have been found dead alone at home with their pumps powered off, raising fears that they may have taken matters into their own hands.

The debate illustrates how new medical technologies often proliferate before society has resolved the issues they raise, such as what to do when a patient has had enough. Similar clashes have arisen over pacemakers and implanted defibrillators, and experts say such predicaments will multiply as researchers rush to develop a host of other replacement organs.

"Anytime you create new forms of life support, you create the possibility for new ethical dilemmas," said Katrina A. Bramstedt, a bioethicist at the California Pacific Medical Center in San Francisco.

The latest quandary centers on left ventricular assist devices (LVADs), which are implanted near the heart and attached to one of the main pumping chambers and the aorta, the main artery supplying blood to the body.

After decades of disappointing attempts to create fully implantable artificial hearts, LVADs emerged as an intermediate crutch to keep transplant candidates alive long enough to get a donated organ. But after researchers discovered that the devices could significantly improve a patient's quality of life, doctors began using them as "destination" therapy, meaning patients would live with them for years with no expectation of a transplant.

"It's a new field," said Soon J. Park, director of the LVAD program at the Mayo Clinic in Rochester, Minn. "There are plenty of people who are sick out there who would benefit from this."

Surgeons at more than 60 centers in the United States are now implanting at least 1,000 LVADs each year. Smaller, more durable and more easily implanted versions are being developed, including one that was approved just this week. With at least 5 million Americans suffering from heart failure, 550,000 new cases being diagnosed each year, only about 2,000 hearts available for transplant each year, and Medicare willing to pay for LVADs (at a typical cost of $200,000), experts predict the number will soar.

"We are at the cusp of a rapid expansion of this type of therapy," said Park, who estimates that within the next five years, 10,000 Americans annually may get the pumps.

The devices are lifesavers for many. They keep some patients alive long enough to get a transplant; maintain others until their hearts heal from surgery, infections or other complications; and sustain a growing pool of people hoping to have a few more decent years.


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