To DT or not to DT, that is the question: working toward a comprehensive, patient-centered perspective on left ventricular assist device for destination therapy.

The machine does not isolate man from the great problems of nature but plunges him more deeply into them. —Antoine de Saint-Exupery Older patients with chronic progressive illness are increasingly facing difficult decisions around potentially life-prolonging technologies. A stark example is destination therapy left ventricular assist devices (DT LVADs), currently offered as a long-term permanent treatment option for patients with end-stage heart failure who are ineligible for heart transplantation. In carefully selected patients, DT LVAD produces marked gains in survival and quality of life measures compared with continued medical therapy. 1 Yet, these striking benefits of DT LVAD come with a host of risks and burdens, which can spill over to caregivers. Meanwhile, the reasons that make patients transplant ineligible in the first place, including noncardiovascular morbidity and frailty, usually persist. 2 Thus, although DT LVADs can be life saving for a period of time under some circumstances, a more holistic view of DT LVAD would characterize it as a complex set of potential trade-offs. Although device technology has evolved at a rapid pace, there has been a much slower evolution in optimal ways to help patients grapple with the medical decisions created by life-prolonging machines. Up until now, there has been a complete absence of any type of evidence summary from which to anchor DT LVAD risk–benefit communication and shared decision making. Optimal informed consent includes not only a description of an operative procedure, but also an understanding of the full range of benefits and risks for the offered therapy and all reasonable treatment alternatives. 3 A patient considering DT LVAD therapy should have a tried-and-true rating system and objective survey research from which to collect and transmit patient-centered information about the DT LVAD decision; yet, there is no equivalent Consumer Reports for the much more important and difficult decision to proceed with DT LVAD. In this issue, Dr Boothroyd et al 4 attempt to move us out of the DT LVAD decision-making darkness by summarizing the full range of expected outcomes for patients, their caregivers, and the clinicians who are charged with conveying such information. This project was initially designed to provide recommendations to the Quebec Ministry of Health, but the universal needs were so evident that the authors have worked to enhance and share their findings with the broader heart failure community. The authors set out to address 3 principle domains they felt were particularly relevant to …