According to an article published in the AMA Journal of Ethics, more formalized curricula in ethics are needed and should be woven into graduate medical education to help physicians navigate specific ethical issues applicable to life-sustaining therapies.
Currently, there is no formal curriculum in medical ethics as it applies to mechanical circulatory support. The authors of this article proposed the integration of ethics of life-sustaining therapies into graduate medical education, focusing on the following constructs: patient best interest, respect for patient autonomy, shared decision-making, and end-of-life care.
Although innovative mechanical circulatory support therapies (including extracorporeal membrane oxygenation, left ventricular assist devices, and total artificial heartstrings) have significantly prolonged survival in patients with heart failure, physicians now face more complex ethical considerations. Complications from mechanical circulatory support include bleeding, stroke, infection, continued heart failure, hemorrhage, and neurological injury; these outcomes, quality of life, and caregiver burden are all considerations when deciding whether to implement mechanical circulatory support therapies.
Residency or fellowship programs that are pertinent to cardiologists and cardiothoracic surgeons who provide mechanical circulatory support for patients with heart failure should ensure exposure to advanced heart failure and mechanical circulatory support devices. Before fellows or residents practice independently, ethics education in cardiology training should integrate important constructs to achieve competency in the following areas: patient best interest, beneficence, and nonmaleficence; respect for a patient’s autonomy; shared decision-making and informed consent; surrogate decision-making; and end-of-life care, including withholding or withdrawing life-sustaining therapies.
Physicians who provide life-sustaining therapies must be further prepared to re-evaluate the appropriateness of therapy, ensuring that the therapy is consistent with a patient’s healthcare goals and is not causing more harm than good. Withdrawing mechanical circulatory support requires consideration of psychosocial and quality-of-life factors. In fact, the removal of such a device is surrounded by considerable ethical debate. Physicians should be trained to manage these ethical dilemmas by balancing benefits and harms with clinical judgment while understanding that each individual patient has his or her own set of preferences and values. Working with surrogate decision-makers requires trainees to be further aware of the emotional impact of caring for a loved one who is ill.
To integrate ethics into graduate medical education, whether using a case-based or bedside-based approach, trainees should practice conversations about the initiation of mechanical circulatory support and how to adapt them to different clinical scenarios. Trainees should be further educated on the importance of regular reexamination of healthcare goals and appropriateness of mechanical circulatory support therapies, as well as the circumstances under which withdrawal of these devices is ethically permissible. The authors recommend that faculty development programs be established that focus on ethics education, and that ethically challenging cases be reviewed in case conferences or meetings, in order to educate a large group of physicians on the application of clinical ethics.
Sonntag EA, Shah KB, Katz JN. Educating resident and fellow physicians on the ethics of mechanical circulatory support [published online May 1, 2019]. AMA J Ethics. doi: 10.1001/amajethics.2019.407