# End-of-life decision-making and changing preferences in patients with a left ventricular assist device for destination therapy: insights from advance directives in Japan

## TL;DR

This study explores how patients in Japan with a left ventricular assist device change their end-of-life care preferences over time.

## Contribution

The study provides new insights into evolving end-of-life preferences among DT-LVAD patients in Japan through advance directives.

## Key findings

- Approximately 30% of patients preferred continued mechanical support until end-of-life at implantation.
- Preferences for independence and home-based end-of-life care increased after one year for patients remaining on DT-LVAD.
- Patients switched to BTT showed a consistent lower inclination toward invasive therapies over time.

## Abstract

End-of-life decision-making and the evolution of patient preferences over time remain insufficiently explored in destination therapy with left ventricular assist device (DT-LVAD) in Japan. This retrospective observational study analyzed standardized advance directives from DT-LVAD patients in Japan. The advance directives comprised (1) preferred end-of-life medical care, (2) designated surrogate decision-makers, and (3) personal life wishes. This study comprises two components: a cross-sectional analysis of all patients at the time of LVAD implantation, and a longitudinal analysis evaluating changes in advance directive preferences among patients who completed the 1-year follow-up assessment. This study included 27 patients who initially received DT-LVAD (median age 47 years, 21 men). At the time of LVAD implantation, approximately 30% of DT-LVAD patients preferred continued mechanical support, including LVAD, mechanical ventilator, and hemodialysis, until the end-of-life stage in a cross-sectional analysis. In addition, 56% preferred receiving end-of-life care at home. In a longitudinal analysis, patients remaining on DT-LVAD showed increased preference for “independence” and “end-of-life care at home” after 1 year of DT-LVAD, whereas their inclination toward invasive treatments decreased. In contrast, patients switched to BTT demonstrated lower inclination toward invasive therapies from the outset, with this tendency becoming more pronounced over time. This study demonstrates the changes in the end-of-life preferences of DT-LVAD patients in Japan. With the continuous increase in the number of DT-LVAD patients, further refinement of advance directive frameworks and the development of structured community-based support systems will be essential for optimizing end-of-life care among LVAD recipients.

The online version contains supplementary material available at 10.1007/s10047-025-01519-6.