Opinion EDITORIAL Albert Liu, MD; Gregory Curfman, MD There is growing evidence that patients have varying priori- decision making is that clinicians are transparent with their rec- ties at the end of their life. Some want to focus on maximiz- ommendations—and their implications, both positive and nega- ing their quality of life, whereas others focus on living longer. tive. When survival benefit is overemphasized and risks are underestimated, patients risk deciding on therapies that are Current clinical practice prioritizes the latter. For example, most 8,9 cardiac device trials use over- inconsistent with their goals. all survival as the primary Left ventricular assist devices may provide symptom re- outcome, instead of quality- lief for patients and improve survival, but they continue to be Related article page 520 2-4 adjusted life years (QALYs). associated with considerable symptoms including pain, What is left unsaid is that these mortality benefits often come major depression, and organic mental syndromes. Device- at a cost: discomfort, loss of mobility, polypharmacy with its related adverse events include stroke, infection, bleeding, attendant adverse effects, procedural complications, device pump thrombosis, ventricular arrhythmias, and right failure, or loss of functional status. ventricular heart failure. Owing to the substantial risk of
JAMA Internal Medicine – American Medical Association
Published: Apr 26, 2018
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