Destination nowhere: A potential dilemma with ventricular assist devices

Increasingly, ventricular assist devices (VADs) are used as destination therapy for those who are not candidates for heart transplantation. Although these devices can benefit patients by improving their functional status and quality of life, they can, in some cases, facilitate an end-point known as "destination nowhere." In such situations, patients and clinicians find themselves in medical limbo where the patient's net benefit is, in fact, a burden, or the continued use of the device has no utility in light of the goals of the technology. This article presents guidance for avoiding "destination nowhere," as well as guidance for ethical care when patients arrive at this juncture.