Elsevier

Heart Rhythm

Volume 7, Issue 11, November 2010, Pages 1537-1542
Heart Rhythm

Focus issue: Device
Clinical
Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: A quantitative assessment

https://doi.org/10.1016/j.hrthm.2010.07.018Get rights and content

Background

Despite the high prevalence of pacemakers and implantable cardioverter-defibrillators, little is known about physicians' views surrounding the ethical and legal aspects of managing these devices at the end of life.

Objective

The purpose of this study was to identify physicians' experiences and views surrounding the ethical and legal aspects of managing cardiac devices at the end of life.

Methods

Survey questions were administered to internal medicine physicians and subspecialists at a tertiary care center. Physicians were surveyed about their clinical experience, legal knowledge, and ethical beliefs relating to the withdrawal of PM and ICD therapy in comparison to other life-sustaining therapies.

Results

Responses were obtained from 185 physicians. Compared to withdrawal of PMs and ICDs, physicians more often reported having participated in the withdrawal or removal of mechanical ventilation (86.1% vs 33.9%, P <.0001), dialysis (60.6% vs 33.9%, P <.001), and feeding tubes (73.8% vs 33.9%, P <.0001). Physicians were consistently less comfortable discussing cessation of PMs and ICDs compared to other life-sustaining therapies (P <.005). Only 65% of physicians correctly identified the legal status of euthanasia in the United States, and 20% accurately reported the legal status of physician-assisted suicide in the United States. Compared to deactivation of an ICD, physicians more often characterized deactivation of a PM in a pacemaker-dependent patient as physician-assisted suicide (19% vs 10%, P = .027) or euthanasia (9% vs 1%, P <.001).

Conclusion

In this single-center study, internists were less comfortable discussing cessation of PM and ICD therapy compared to other life-sustaining therapies and lacked experience with this practice. Education regarding the legal and ethical parameters of device deactivation is needed.

Introduction

Navigating end-of-life care for patients who require life-sustaining devices can be clinically and ethically challenging.1 Physicians have reported a lack of confidence in approaching end-of-life care decisions involving therapies such as dialysis and mechanical ventilation.2, 3, 4, 5, 6 Patients have reported an interest in participating in these decisions, although comfort and understanding vary considerably according to the setting and complexity of the intervention.7, 8, 9 Withdrawal of life-sustaining therapies has even led to significant public controversy and debate in cases such as the legal battle to remove Terri Schiavo's feeding tube.10, 11

Permanent heart rhythm devices, such as pacemakers (PM) and implantable cardioverter-defibrillators (ICDs), prolong patients' lives across a wide spectrum of cardiovascular diseases.12, 13, 14 Currently, more than two million patients have these devices,15 and this number will continue to grow due to an aging U.S. population and expanding clinical indications.16, 17 Despite the effectiveness of heart rhythm devices, clinical studies demonstrate 5% to 20% annual mortality rates for recipients, meaning that tens of thousands of deaths occur annually among these patients.12, 13, 14, 18 Therefore, physicians caring for this broadening population of device recipients will inevitably be confronted with the possibility of device deactivation.

Little research is available to guide physician decision-making regarding these devices at patients' end of life despite the challenges involved in management.1, 19, 20, 21, 22, 23, 24 Immediate death or acute cardiovascular symptoms may follow deactivation of devices treating heart rhythm abnormalities or heart failure, and these outcomes may be unpredictable and beyond the experience of some physicians.21 Many physicians are uncertain about the experience of clinical arrhythmias or ICD shocks, making communication with patients more difficult.23, 24, 25, 26 A study of heart rhythm specialists with substantial personal experience deactivating devices suggested that, despite frequently performing deactivations, many remained uncomfortable with the practice and favored involvement of psychiatric and/or ethics consultations.22 The specific reasons for these views, however, are not clear.

Similarly, although studies have suggested that many physicians view PM and ICD deactivation differently than withdrawal of other life-sustaining therapies, the underlying basis for those views remains poorly understood.20, 22, 23, 24, 27 Physicians may have legal, ethical, or other objections to PM and ICD deactivation. Reluctance to withdraw these therapies may be related to attitudes and knowledge surrounding end-of-life care in general. In particular, the views of physicians apart from arrhythmia specialists have not been adequately explored despite their frequent responsibilities managing these patients at the end of life.16

To shed more light on this complex and increasingly common area of health care delivery, we surveyed internal medicine physicians and subspecialists about their specific ethical beliefs and legal knowledge relating to the withdrawal of PM and ICD therapy in end-of-life patients. We then compared these results to their views on withdrawing other life-sustaining therapies.

Section snippets

Study population and recruitment

All internal medicine physicians and internal medicine subspecialists at Beth Israel Deaconess Medical Center, an academic tertiary care center in Boston, Massachusetts, were eligible for study participation. These 746 physicians included 471 clinical attendings, 158 residents, and 117 subspecialty fellows. Physicians were recruited to participate by e-mail through an anonymous link (no honorarium offered). Research was conducted with approval of the Beth Israel Deaconess Medical Center

Results

We received responses from 185 (25%) physicians (Table 1). Among the 153 responders who provided professional training data, nearly all were trained as internists (150 [98%]), and most practiced at the level of clinical attending (119 [69%]). Among the physicians reporting additional subspecialty training, the most common fields were cardiology (13 [8.5%]), pulmonary/critical care (13 [8.5%]), and geriatrics (8 [5.2%]).

Discussion

This study expands the understanding of internal medicine physician practices, knowledge, and beliefs regarding PM and ICD deactivation. Although most physicians expressed confidence in discussing end-of-life care in general, some lack experience and comfort in managing cardiac devices specifically at the end of life and have important gaps and inconsistencies in their legal and ethical knowledge pertaining to cessation of PM and ICD therapy. Notably, 25% to 49% of physicians considered

Conclusion

In this single-center study, internists were less comfortable discussing cessation of PM and ICD therapy compared to other life-sustaining therapies and lacked experience with this practice. Efforts to better educate health care providers about the methods, clinical implications, ethics, and legality of device deactivation should be undertaken.

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    This research was conducted with the support of a pilot grant from Harvard Catalyst The Harvard Clinical and Translational Science Center (NIH Grant 1-UL1-RR025758-02 and financial contributions from participating institutions). Dr. Kesselheim is supported by a career development award from the Agency for Healthcare Research and Quality (K08HS18465-01).

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