179 Background In the management of advanced heart failure, the option of long-term mechanical circulatory support (MCS) as destina- tion therapy (DT), rather than as a temporary bridge to cardiac transplantation, is increasingly being offered to highly selected patients. Recent technological advancements in implantable devices, such as continuous flow systems and smaller pump sizes, have increased the possibility of survival with fewer complications. Informed consent before MCS is essential 1–6 and is a fundamental aspect of patient-centered care. As a part of a quality decision-making process, the patient considering MCS and his/her informal caregiver(s) need to be aware of the current state of the scientific evidence, including what is known and unknown about outcomes and living with MCS and must navigate a series of interactions with clinicians before deciding on the treatment course. Editorial see p 13 The Institut National d’Excellence en Santé et en Services Sociaux is a health technology assessment and clinical guideline development organization in the province of Quebec (Canada) that provides multiple stakeholders (ie, government officials, hospital administrators, physicians, and patient organizations) with evidence-based informa- tion. In 2011, the Quebec Ministry of Health requested that the Institut National d’Excellence en Santé et en Services Sociaux provide recommendations on the use of implantable left ventricular assist devices in end-stage chronic heart fail- ure. The current article extends the work submitted to the Ministry 1 and focuses on MCS use in DT, within the frame- work of informed decision making. In this perspective piece, we report on our review of the scientific literature concerning clinical outcomes in DT and on perspectives of DT patients and their caregivers, to pro- vide a summary of currently available information and iden- tify gaps in knowledge. Besides the use of MCS as a bridge to transplantation, we do not consider in this perspective the other clinical recourses to MCS (rescue therapy and bridge to decision) where circumstances may make the informed decision-making process particularly problematic. Our work is aimed at not only specialists in the field but also the gen- eral cardiology audience that may not be familiar with this specialized literature. Our methods included a search of the peer-reviewed scientific literature published in English or French from January 2000 to the end of December 2012, using the PubMed bibliographic database and key words and reference lists of retrieved documents. We consulted primary research articles and consensus scientific state- ments, expert opinion editorials, and review articles. The most recent clinical practice guidelines concerning MCS by the International Society for Heart and Lung Transplantation and the most recent annual report of the Interagency Registry for Mechanically Assisted Circulatory Support, at the time of our review, were also consulted. We extracted data on out- comes from all empirical studies of DT patients who received HeartMate II (the implantable device currently most often used for DT) and that were published since 2008 (the year in which the device was approved for DT in the United States). We also extracted data from all empirical studies that involved ≥1 DT patients (or informal caregiver of a DT patient) on liv- ing with MCS, providing care to a recipient, or terminating MCS. For studies with mixed patient populations, informa- tion specific to DT patients was extracted whenever possible. An independent committee of clinical experts (1 cardiologist [A.D.] and 3 cardiac surgeons [É.C., M.C., R.C.]), active in the MCS domain, assisted with the interpretation of results. Framework: Informed Decision Making Informed decision making is an ethical norm and legal man- date, which refers to the voluntary choosing of an inter- vention (or of no intervention) by a patient, or by his/her decision-making proxy, in light of ongoing discussion with (Circ Cardiovasc Qual Outcomes. 2014;7:179-187.) © 2014 American Heart Association, Inc. Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org DOI: 10.1161/CIRCOUTCOMES.113.000243 Cardiovascular Perspective From the Institut National d’Excellence en Santé et en Services Sociaux, Montreal, Quebec, Canada (L.J.B., L.J.L., J.R.G., G.S., J.E.M., P.B.); Institut de Cardiologie de Montréal, Montreal, Quebec, Canada (A.D., M.C.); Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada (J.R.G.); Institut Universitaire de Cardiologie et Pneumologie de Québec, Quebec, Canada (É.C., P.B.); and McGill University Health Centre, Montreal, Quebec, Canada (R.C., J.E.M.). The Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.113.000243/-/DC1. Correspondence to Lucy J. Boothroyd, PhD, INESSS, 2021 Union Ave, Suite 10.083, Montreal, Quebec H3A 2S9, Canada. E-mail lucy.boothroyd@ inesss.qc.ca Challenge of Informing Patient Decision Making What Can We Tell Patients Considering Long-Term Mechanical Circulatory Support About Outcomes, Daily Life, and End-of-Life Issues? Lucy J. Boothroyd, PhD; Laurie J. Lambert, PhD; Anique Ducharme, MD, MSc; Jason R. Guertin, MSc; Georgeta Sas, MD, MSc; Éric Charbonneau, MD; Michel Carrier, MD; Renzo Cecere, MD; Jean E. Morin, MD; Peter Bogaty, MD by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from by guest on August 27, 2016 http://circoutcomes.ahajournals.org/ Downloaded from