LVAD destination therapy: applying what we know about psychiatric evaluation and management from cardiac failure and transplant.

Left ventricular assist devices (LVADs) have evolved into long-term use as destination therapy for those with severe end-stage heart failure due to other medical risks. Success with LVAD depends on adherence to a complicated mechanical regimen, and acceptance of a life that is far from normal. Patients with LVADs share characteristics with other end-stage cardiac failure patients and those waiting for or receiving heart transplants. Understanding the more thoroughly studied issues of psychiatric disorders, adherence, and behavioral correlates of success in heart failure and transplantation may identify feasible strategies for optimizing care of LVAD patients and suggest directions for future research. Depression and distress complicate post-transplant care. Psychiatric morbidity is associated with poor outcomes, including graft rejection, non-adherence, hospitalizations, infection, and death. With a high risk of embolic neurological events, patients' ability for self-care may be compromised. Psychiatric symptoms are underdiagnosed and undertreated, which may impact overall survival and quality of life.

The evolving approach to ethical issues in living donor kidney transplantation: a review based on illustrative case vignettes.

Living donor kidney transplantation which involves performing a major surgical procedure on a healthy person solely to benefit another person has always involved dealing with difficult ethical issues. Beneficence, non-maleficence, donor autonomy, altruistic donor motivation, coercion-free donation, fully informed consent and avoidance of medical paternalism have been the dominant ethical principles governing this field ever since the first successful living donor kidney transplant in 1954. The increasing reliance on living donors due to the rapidly growing disparity between the number of patients awaiting transplantation and the availability of deceased donor kidneys has brought with it a variety of new ethical issues of even greater complexity. Issues such as confidentiality of donor and recipient medical information, the appropriateness of the invented medical excuse to avoid donation and the approach to misattributed paternity discovered during work-up for living donor transplantation have made the information to be disclosed prior to obtaining donor's consent much more extensive. In this article, we review the current thinking and guidelines (which have evolved considerably over the past several decades) regarding these ethical issues using five illustrative case vignettes based on donors personally evaluated by us over the past 35 years.