Ethics

What is the physician role in patients’ experience of death? 

About 6.5 million adults in the U.S. are living with heart failure, and about half of those patients will die within five years of diagnosis. Heart transplantation offers a cure for patients with advanced chronic heart failure or acute unrecoverable decompensation. There is an increasing number of patients with end-stage heart failure, yet availability of donor hearts is decreasing. This leaves physicians to consider options such as mechanical circulatory support or other advanced cardiopulmonary care technologies.

These life-sustaining therapies can postpone certain death, reshape physicians’ views of what should be considered good end-of-life care, and prompt examination of what a doctor’s role might be in a patient’s experience of death. While physicians weigh the benefits of technological advancements against risks of harm, it is important to keep patients at the forefront of considerations.

The May issue of the AMA Journal of Ethics® (@JournalofEthics) features numerous perspectives on advanced cardiopulmonary care ethics and gives you an opportunity to earn CME credit.

Articles include:

Should Physicians Offer a Ventricular Assist Device to a Pediatric Oncology Patient With a Poor Prognosis?” A 10-year-old girl with refractory leukemia has a poor prognosis and chemotherapy-induced heart failure. She is evaluated for a ventricular assist device (VAD), but the pediatric heart failure team views VAD as clinically inappropriate due to her active oncologic problems. This article examines ethical concerns that arise in deciding whether to offer and use this technology.

How Should Physicians Respond to Requests for LVAD Removal?” Mechanical circulatory support devices, including left ventricular assist devices (LVADs), have become mainstream treatment for end-stage heart failure. LVADs are ethically and legally no different than other types of life support, for which patients have a right to decline or withdraw care consistent with the principle of respect for autonomy. However, the realities of LVAD complicate informed consent and shared decision making. LVAD candidates are often older and have multiple illnesses.

Life with an LVAD requires a period of comprehension, adaptation, and reintegration. Therefore, physicians must assess LVAD candidates’ decision-making capacity, screen and possibly consult for depression, seek to understand whether being on LVAD is consistent with patients’ values, consider temporary support options to allow for goals clarification, and ask for help from family and palliative care specialists.

Should Long-Term Life-Sustaining Care Be Started in Emergency Settings?” Decision making on behalf of an incapacitated patient is challenging, particularly in the context of venoarterial extracorporeal membrane oxygenation (VA-ECMO), a medically complex, high-risk, and costly intervention that provides cardiopulmonary support. In the absence of a surrogate and an advance directive, the clinical team must make decisions for such patients.

Because states vary in terms of which decisions physicians can make, particularly at the end of life, the legal landscape is complicated. This article about withdrawal of VA-ECMO in an unrepresented patient discusses Extracorporeal Life Support Organization guidelines for decision making, emphasizing the importance of proportionality in a benefits-to-burdens analysis.

How Should ECMO Initiation and Withdrawal Decisions Be Shared?” Extracorporeal membrane oxygenation (ECMO) is a new technology used to rescue patients with severe circulatory or respiratory failure and help bridge them to recovery or to definitive therapies like device implantation or organ transplantation. The increasing availability and success of ECMO has generated numerous ethical questions about its use and potential misuse. This article about a patient who is no longer a candidate for transplant but wishes to continue ECMO identifies strategies physicians can use to reconcile competing responsibilities.

Listen and learn

In the journal’s May podcast, guests include:

  • Elizabeth Sonntag, MD, a pulmonary and critical care fellow at the University of North Carolina at Chapel Hill.
  • Daniel Brauner, MD, an associate professor of medicine in the Section of Geriatrics and Palliative Medicine at the University of Chicago and co-director of the MacLean Center for Clinical Medical Ethics Consultation Service.
  • Nicholas Braus, MD, a pulmonologist and critical care physician at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin.

The episode discusses how the evolving indications for last-resort life support technologies pose unique challenges. Experts also address when ECMO should be started, and when it should be stopped. Listen to previous episodes of the podcast, “Ethics Talk,” or subscribe in iTunes or other services.

Submit manuscripts and artwork

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

The AMA Journal of Ethics  Conley Art of Medicine contest and Conley Ethics Essay contest for medical students, residents, and fellows are now open.

A look ahead

Upcoming issues of the AMA Journal of Ethics will focus on limits to patient preferences and ethics of representing unrepresented patients. Sign up to receive email alerts when new issues are published.

The AMA Journal of Ethics exists to help health professions students and clinicians navigate ethical decisions in service to patients and society by offering cases and analyses, medical education articles, policy discussions, peer-reviewed articles for journal-based CME, visuals, and more. The journal is open-access (no subscription or publication fees) and offers a blend of peer-reviewed content and articles we solicit experts to write.

The journal’s call for theme issue editors is now open. Medical students, residents and fellows in U.S.-based programs are invited to apply to serve as theme issue editors for monthly issues to be published in 2021–2022.