In the United States alone, an estimated 100,000 patients per year receive implantable cardioverter defibrillators (ICDs) – devices that detect life-threatening heart rhythm irregularities and deliver a high-voltage shock to return the heart to a normal pace. Despite their lifesaving purpose, many patients and clinicians will ultimately be faced with difficult decisions about deactivation of these devices as patients age and develop other conditions that may prove terminal. Little is understood about physicians' views surrounding the ethical aspects of ICD deactivation in end-of-life situations, especially as it relates to other medical interventions and patient and family directives.
Now, new research from the Perelman School of Medicine at the University of Pennsylvania has revealed that many electrophysiology practitioners believe ICD and pacemaker deactivation to be ethically distinct and that an ICD should not be deactivated without discussion with patients and families, even in the face of medical futility. The study results were reported today at the 2013 American College of Cardiology meeting in San Francisco (Abstract # 1277-28).
"Decisions by medical providers not to resuscitate patients, despite patient and/or family wishes to the contrary, are extremely controversial. However, they have been argued to be ethically justified in cases of medical futility and may be gaining traction in an era of cost-consciousness, concern over ICU beds as a scarce resource, spiraling costs of care at the end of patient's lives, and frustrations on the part of medical providers over the provision of futile care," said senior study author James N. Kirkpatrick, MD, assistant professor in the Cardiovascular Medicine Division and the Department of Medical Ethics and Health Policy at Penn. "In general, medical providers are not expected to provide care they believe is futile. Most patients and providers see no ethical distinction between defibrillation by an ICD and external defibrillation in the performance of CPR. In this study, we sought to explore ethical beliefs of clinicians regarding deactivation of ICDs in end-of-life situations, including deactivation against patient and family/surrogate wishes, known as unilateral deactivation."
To better understand practitioners' viewpoints, the research team polled 383 electrophysiology providers (including doctors, nurses, technicians) to gain insights into the ethical considerations involved in deactivation. Seventy-seven percent of respondents indicated that an ICD should not be unilaterally deactivated, whether against the wishes of a patient or against the wishes of the family/surrogate, even in the face of medical futility.
They also found that 43 percent of respondents believe that ICDs were not like any other medical intervention, including external defibrillation, dialysis, and coronary stents. In regards to other life-sustaining interventions, 73 percent of respondents indicated that deactivating an ICD was not ethically/morally different than not performing CPR; however, 83 percent of respondents indicated that deactivating a pacemaker was ethically/morally different than deactivating the shocking function of an ICD.
"In our study, there was a mixed response regarding the ethical nature of ICDs and the justification for deactivating them in end-of-life situations, but most of the sample did not believe ICDs fit into any of our currently accepted categories for types of therapies we withdraw, such as mechanical ventilation," said Dr. Kirkpatrick. "Based on these findings, we need to further explore ways to help clinicians address end-of-life management of ICDs."
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