A Patient's Request to Withdraw a Ventricular Assist Device: The Role of the Consulting Psychiatrist Among Evolving Medical Technologies

The decision to withdraw life-sustaining care usually takes place in intensive care settings, with family members often making choices for an intubated or otherwise incapacitated patient following unsuccessful interventions or when aggressive treatment is likely futile. However, a patient requiring a ventricular assist device may be lucid and interactive, with the capacity to make decisions pertaining to his or her own health. The decision to use or withdraw the device is often complicated. A consultation-liaison psychiatrist can help mediate discussions among various parties regarding such life-altering decisions. The case report below is of an elderly man who requested withdrawal of a ventricular assist device.

Case

"Mr. H" is a 69-year-old Caucasian, married man who was initially admitted to a tertiary hospital for acute ST-elevation myocardial infarction as a result of a severe coronary artery condition that was undiagnosed. His hospital course was complicated by persistent arrhythmia and severely diminished left-ventricular ejection fraction. Subsequently, an automatic implantable cardioverter defibrillator was implanted. The patient's condition stabilized, and he was discharged home after 10 days of cardiac rehabilitation.

Two weeks following his initial discharge, the patient was readmitted for automatic implantable cardioverter defibrillator firing due to recurrent episodes of ventricular tachycardia. He presented to the hospital in cardiogenic shock and hypoxemic respiratory failure. He was intubated, pressors were initiated, and an intra-aortic balloon pump was emergently inserted. Following the procedure, the patient developed intractable ventricular tachycardia storm, necessitating repeated electrical cardioversion. Severe biventricular failure led to persistent hemodynamic collapse, and a temporary, extracorporeal biventricular assist device was emergently implanted via sternotomy.

Amid severe cardiac failure, the patient was intubated and sedated, and he was unable to participate in decision making pertaining to his medical condition. He had not previously appointed a health care proxy, and thus consent for biventricular assist device placement was obtained from his wife of 50 years. His wife consented to biventricular assist device placement informed by what she presumed her husband would want.

The patient's hemodynamic stability was restored while he was receiving biventricular assist device support, his end-organ function was normalized, and he was eventually extubated. Upon regaining consciousness, he was approached by his cardiothoracic surgery team to discuss placement of a permanent left ventricular assist device as a destination therapy. The patient declined left ventricular assist device placement and requested that the biventricular assist device be turned off, despite certain and imminent demise. The consultation-liaison psychiatry service was then consulted to assess the patient's capacity to request withdrawal.

The patient had no personal or family history of psychiatric or substance abuse. He denied any history of suicidal ideation or attempts. His birth and childhood histories were unremarkable. After graduating from high school, he ascended the ladder of management from apprenticeship in a successful printing company. He retired after 40 years at the company, 10 years before his hospitalization. He maintained an active and financially stable life with his wife, working as a contractor, vacationing with family, and maintaining three family-owned rental properties. His family denied any concern for functional or cognitive decline before his myocardial infarction and confirmed that he had an excellent premorbid quality of life.

To the examining psychiatrist, the patient said, "I can't live this way. This is what I want: I want pain medication, to go to sleep. Disconnect all of these tubes, and then, I won't wake up." He endorsed feelings of demoralization about his recent physical decline and recurrent hospitalizations. While he fully understood that ventricular assist device withdrawal was fatal, he denied any active suicidal thoughts. His family described the initial heart attack as a "devastating" event for him, because he was a "fiercely independent" man who grieved the loss of his autonomy and vigor. He reported feeling somewhat irritable, since his cardiac condition substantially limited the activity level that he had before his second hospitalization, but his family did not otherwise suspect that he was depressed.

The patient's decision to withdraw the ventricular assist device created discord within his family. However, after a family meeting, which was moderated by the consultation-liaison psychiatrist, the family agreed that the patient expressed preferences consistent with his premorbid health care goals. Psychiatric examination revealed no major psychiatric symptoms. The patient was medically frail and at times in pain, but he did not appear to be clinically depressed. His cognition was intact, and he had a Mini-Mental Status Examination (MMSE) score of 28/30. He was in a consistent state of consciousness and orientation, with no evidence of delirium, as determined by the Confusion Assessment Method for the ICU. He demonstrated intact insight and judgment while he rationally explained why he wanted the ventricular assist device to be disconnected. This decision was reportedly informed by his anticipated quality of life, his preferences for end-of-life care, and a verbalized appreciation for the immediacy of likely demise. The consultation-liaison psychiatrist therefore concluded that the patient did have the capacity to make this critical decision. His primary medical team disconnected the biventricular assist device, and he expired several hours later, surrounded by his family.

Discussion

With growing sophistication of life-sustaining technologies, the role of the psychiatrist has become increasingly important in a multidisciplinary model of care delivery. Psychiatrists have unique expertise to assess premorbid functioning, cognition, delirium, and capacity and can provide medical teams with a balanced and objective approach in determining a patient's mental state. Distinguishing appropriate reactions to pain or severe morbidity from clinical depression or suicidality is imperative, and at times quite challenging. The psychiatrist's role can be paramount in assuring that appropriate and respectful decisions are made.

For the nearly half-million U.S. patients with end-stage heart failure refractory to maximal medical management, placement of a ventricular assist device is a treatment option that may prolong life and improve the quality of life (1). Originally developed as a "bridge" to heart transplantation, ventricular assist device placement is currently considered a "destination therapy" for patients who are not eligible for a heart transplant due to advanced age, complex medical comorbidities, or severe psychosocial problems. Despite positive statistics, left ventricular assist device technology requires significant daily maintenance and places activity limitations upon the patient. Furthermore, it can be associated with serious postoperative complications, rehospitalization, and long-term medical care. Similar to the patient described in the above case, a substantial number (nearly 20%) of patients with end-stage heart failure choose not to have a ventricular assist device implanted (2, 3). Even after ventricular assist device placement, a request for discontinuation is made by up to 20% of patients or their family members (4).

When considering a patient's request to disconnect a ventricular assist device, the foremost priority of the consultation-liaison psychiatrist is to assess the patient's capacity to make such a critical decision. The four principles of evaluating whether a patient has the capacity to make medical decisions remains standard. The patient must communicate a consistent choice, understand relevant information, appreciate the situation and consequences of the choice, and rationally process appropriate information (5). Notably, cognitive impairment is common among patients with heart failure and becomes more prominent with increasing severity of illness, and delirium is highly prevalent in the intensive care unit (6, 7). Careful assessment of a patient's cognitive capacity to make decisions is critical. The use of simple, formal cognitive tests, such as the Confusion Assessment Method for the ICU, MMSE, and Montreal Cognitive Assessment, can quickly and sensitively rule out delirium or dementia.

Additionally, the consultation-liaison psychiatrist should screen for comorbid psychiatric disorders that might interfere with a patient's decision-making capacity. Depression is present among more than 20% of patients with heart failure, and the rate of depression is double that among patients with advanced heart failure (8). The neurovegetative symptoms of depression can be difficult to distinguish from symptoms associated with severe heart failure. Severe depression can impair a person's decision-making capacity, most notably compromising the ability to appreciate pertinent information and anticipated outcomes (9). The decision to withdraw a ventricular assist device hastens imminent death, and therefore understanding a patient's presurgical personality characteristics, outlook, and future orientation is critical in establishing whether the patient's own medical decisions are consistent with his or her presurgical disposition. Ideally, goals of care should be explored and documented in times of stable health and cognitive clarity and should be reviewed with family members before placement of a ventricular assist device.

Preferably, each candidate for a ventricular assist device is evaluated by a psychiatrist, who should be a part of the advanced heart failure team, to assess the patient's presurgical cognitive status and functioning and to identify comorbid psychiatric factors that might interfere with care following implantation of the device. Once potential neurocognitive or psychiatric barriers are identified, the psychiatrist should assist the team in preparing appropriate postimplantation psychosocial supports to compensate for any neuropsychiatric vulnerability. Although the psychiatrist does not recommend or determine candidacy, he or she should provide guidance to the primary team regarding current and future potential psychiatric barriers, act as a liaison between parties, and advocate for patients who might otherwise be excluded from candidacy due to comorbid psychosocial or psychiatric conditions.

As our ability to sustain and prolong life increases, we must be prepared for our patients to tell us that they want to die. Although this may evoke feelings of discomfort among some physicians, the consultation-liaison psychiatrist can play an important role in assisting patients, families, and primary medical teams to make the best decision that respects patients' preferences and values. To do so may feel especially unnatural for psychiatrists, because we operate in a model that pathologizes suicidality. However, distinguishing depression-related suicidality from a wish to withdraw unwanted care is essential. The prevailing view in the medical field about ventricular assist device discontinuation is similar to that regarding removal of a ventilator-assisted device: withdrawal of life-sustaining care in accordance with the wishes of the patient and/or family members. At present, case law prioritizes the wishes of the patient and obligates the physician to withdraw life-sustaining technology, including a ventricular assist device, if this is expressed.

With increasingly sophisticated and costly medical technology available to prolong life, psychiatrists play a meaningful role in optimizing the quality of care as well as justice. An assessment can lead to careful consideration of psychosocial factors influencing end-of life decisions. In all cases, psychiatrists can help to maximize patient autonomy and guide the primary team and patient toward responsible and respectful choices.

Key Points/Clinical Pearls