**4. Ethics in LVAD as DT**

Left ventricular assist systems (LVAD) are widely used to treat patients with heart failure refractory to medical therapy as a bridge to heart transplantation [7]. In subjects who have severe comorbidities such as compromising their inclusion in the transplant list, LVADs can be used as definitive therapy (Destination Therapy - DT). This use implies a series of ethical aspects that include the correct selection of the patient, the patient's precise information, and the definition of a possible protocol for deactivating the LVAD [8]. There are three ethical considerations regarding the selection of patients: the inclusion and exclusion criteria must be clearly explained, justified by rational diagnostic-therapeutic paths, and frequently discussed with the patient during the evaluation phase: The medical criteria must be supported by the most current medical, scientific evidence; The assessment must be conducted based on an explicit weighting of the costs, benefits, and risks associated with the procedure to be applied. The physician is responsible for providing clear information to the patient and family members, clarifying the risks and benefits of different treatment options, including medical treatment, palliative care, and VAD as destination therapy. The patient must be informed about the treatment's goal as an innovative surgical procedure aimed at improving the quality of life. An advanced treatment plan must be presented to the patient, clarifying the patient's preferences in case of complications. It is advisable to propose different scenarios that may occur during daily life through an interview with other subjects with LVAD.

Another ethical aspect concerns the possible interruption of therapy with mechanical support [9]. According to the principle of self-determination, the patient is fully entitled to stop medical treatment so that natural death can occur. A natural death can occur as a consequence of the deactivation of an LVAD due to a dysfunction of the device, due to coexisting comorbidities, or as a consequence of the progression of the disease. There are two ways of deactivating the LVAD. A team can help the patient disconnect the device from the power supply to cause a stop of the pump. The device's interruption does not result in euthanasia since the ventricular function was already severely depressed before implanting the LVAD; the patient's death occurs from the underlying heart disease. The second option involves surgical removal, but this alternative is somewhat complicated because it could cause the patient's death and then. After all, it would contravene the goal of ensuring patient comfort [10].
