Focus issue: DeviceClinicalEthical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: A quantitative assessment
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.
References (32)
- et al.
HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy: developed in collaboration with the American College of Cardiology (ACC), the American Geriatrics Society (AGS), the American Academy of Hospice and Palliative Medicine (AAHPM); the American Heart Association (AHA), and the European Heart Rhythm Association (EHRA)
Heart Rhythm
(2010) - et al.
Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members
Chest
(2006) - et al.
The seriously ill hospitalized patient: preferred role in end-of-life decision making?
J Crit Care
(2003) - et al.
Goal setting as a shared decision making strategy among clinicians and their older patients
Patient Educ Couns
(2006) - et al.
Physicians' preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator
Mayo Clin Proc
(2008) - et al.
Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians
J Am Coll Cardiol
(2009) - et al.
HRS/EHRA expert consensus on the monitoring of cardiovascular implantable electronic devices (CIEDs): description of techniques, indications, personnel, frequency and ethical considerations
Heart Rhythm
(2008) - et al.
Physicians' confidence in discussing do not resuscitate orders with patients and surrogates
J Med Ethics
(2008) - et al.
Why is it difficult for staff to discuss advance directives with chronic dialysis patients?
J Am Soc Nephrol
(1996) - et al.
Nephrologists' reported attitudes about factors influencing recommendations to initiate or withdraw dialysis
J Am Soc Nephrol
(1991)
Physicians' decisions to withhold and withdraw life-sustaining treatment
Arch Intern Med
Decisions near the end of life: professional views on life-sustaining treatments
Am J Public Health
“Culture of life” politics at the bedside—the case of Terri Schiavo
N Engl J Med
Terri Schiavo—a tragedy compounded
N Engl J Med
The effect of cardiac resynchronization on morbidity and mortality in heart failure
N Engl J Med
Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure
N Engl J Med
Cited by (65)
Managing Implantable Cardioverter-Defibrillators at End-of-Life: Practical Challenges and Care Considerations
2019, American Journal of the Medical SciencesCitation Excerpt :Further, it revealed that cardiologists and cardiac electrophysiologists were more likely than internists and geriatricians to be aware of pain and distress related to ICD shocks,46 but were less enthusiastic about a mandatory discussion on deactivation options as part of informed consent. In a survey of 185 attending and trainee physicians at a large U.S. teaching hospital, 89% felt comfortable discussing end-of-life in general, but 34% felt uncomfortable with discussions regarding ICDs compared to other life-prolonging therapies such as mechanical ventilation, feeding tubes and dialysis.47 A physician's prior knowledge and experience with device deactivation as well as experience with these discussions play a major role in the comfort in initiating this conversation.46
2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society
2018, Journal of the American College of CardiologyArrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes
2018, Journal of the American College of CardiologyCitation Excerpt :About one-fourth of patients may receive ICD shocks during the last 24 h of life, leading to unnecessary suffering (107). Although it is reasonable to consider deactivating ICDs in terminally ill patients, many patients are not aware of this option, as most physicians may not bring up the subject because they are uncomfortable with it or question the legality (108). It is important that a shared decision about ICD therapy be made with the patient and the family at the time of device implantation or generator change, and as a part of advanced care planning for terminally ill patients.
Increased Incidence of Ventricular Arrhythmias in Patients With Advanced Cancer and Implantable Cardioverter-Defibrillators
2017, JACC: Clinical ElectrophysiologyCitation Excerpt :ICD deactivation is sometimes perceived as a form of assisted suicide (29). In addition, studies show that many physicians report a lack of confidence when discussing cessation of ICD therapy (29,30). This study has certain strengths.
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).