HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy

Implantable cardioverter-defibrillator recipient attitudes towards device deactivation: how much do patients want to know?

BACKGROUND

Patients receiving implantable cardioverter-defibrillators (ICDs) often have severely impaired left ventricular function and a poor prognosis. Having an ICD in situ effectively denies them the possibility of a quick, arrhythmic death. It is still unclear if and when the end of life and device deactivation should be discussed with patients and how much patients want to know prior to ICD implantation.

METHODS

Patients with an active ICD for chronic heart failure were interviewed regarding their attitude toward the ICD, their recollection of the consent procedure, and how they felt the end of life should be discussed with ICD patients (n = 54). Patients who had received ICD therapies (n = 25) were reviewed as a subgroup with extended questions regarding attitudes toward device deactivation.

RESULTS

Fifty-four patients were recruited. Most patients were not aware that the ICD could be deactivated. The vast majority of patients (84%) wanted to be involved in the deactivation decision; 40% felt this discussion should be prior to ICD implantation but others felt the discussion should only occur if the patient was terminally ill (16%) or in the last few days of life (5%).

CONCLUSION

Patients with ICDs are routinely counseled about the benefits of ICDs, but options for device deactivation are not well understood by patients. Most patients would like to be involved in deactivation decisions and we feel this should be discussed well in advance.

Is pacemaker deactivation at the end of life unique? A case study and ethical analysis

Although there has been considerable controversy regarding the deactivation of pacemakers near the end of life, clinicians can expect to face more requests for pacemaker withdrawal as the number of implants grows. Despite a clear ethical and legal precedent, these requests may elicit significant psychological and moral distress on the part of the clinical team. We illustrate some of the difficulties clinicians may face by describing the case of a patient with end-stage heart failure who asked to have her pacemaker turned off near the end of life. We discuss the challenges in determining pacemaker dependency, differing attitudes toward deactivating pacemakers versus other cardiac devices, and how the issues of perceived burden and timing of death may contribute to a clinician's sense of moral distress.

"I felt like the angel of death": role conflicts and moral distress among allied professionals employed by the US cardiovascular implantable electronic device industry

PURPOSE

This study aimed to identify themes associated with role conflicts and moral distress experienced by cardiovascular implantable electronic device (CIED) industry-employed allied professionals (IEAPs) in the clinical setting.

METHODS

Focus groups were used to elicit perspectives from IEAPs who had deactivated a CIED.

RESULTS

Seventeen IEAPs (five women) reported increased clinical presence and work-related role conflicts and moral distress along several themes: (1) relationships with patients, (2) relationships with clinicians, (3) role ambiguity, (4) customer service to clinicians, and (5) CIED deactivation. Patients often misperceived IEAPs as physicians or nurses. Many physicians expected IEAPs to perform clinical duties. Customer service obligations exacerbated IEAP role conflicts and moral distress because of dual agency. IEAPs commonly received and carried out requests to deactivate CIEDs; doing so, however, generated considerable distress-particularly deactivations of pacemakers in pacemaker-dependent patients. Several described themselves as "angels of death." IEAPs had recommendations for mitigating role conflicts and moral distress, including improving the deactivation process.

CONCLUSIONS

IEAPs experienced role conflicts and moral distress regarding their activities in the clinical setting and customer service obligations. Health care institutions should develop and enforce clear boundaries between IEAPs and clinicians in the clinical setting. Clinicians and IEAPs should adhere to these boundaries.

"Just Because We Can Doesn't Mean We Should": views of nurses on deactivation of pacemakers and implantable cardioverter-defibrillators

PURPOSE

This study aims to identify nurses' concerns about the clinical, ethical, and legal aspects of deactivating cardiovascular implantable electronic devices (CIEDs).

METHODS

We used focus groups to discuss decision making in CIED management.

RESULTS

Fourteen nurses described the informed consent process as overly focused on procedures, with inadequate coverage of living with a device (e.g., infection risks and device shocks). Elderly patients were especially vulnerable to physician or family pressure about CIED implantation. Nurses believed that initial advance care planning discussions were infrequent and rarely revisited when health status changed. Many patients did not know that CIEDs could be deactivated; it was often addressed reactively (i.e., after multiple shocks) or when patients became too ill to participate in decision making. Nurses generally were supportive of CIED deactivation when it was requested by a well-informed patient. However, nurses distinguished between withholding versus withdrawing treatment (i.e., turning off CIEDs vs. declining implantation). Although most patients viewed their device as lifesaving, others perceived them as a "ticking time bomb."

CONCLUSIONS

Nurses identified concerns about CIED decision making from implantation through end-of-life care and device deactivation and suggested avenues for improving patient care including early and regular advance care planning.

The ethics of pacemaker deactivation in terminally ill patients

A core principle of American medical ethics holds that an informed and capacitated patient has the right to have treatments withdrawn or withheld. Nevertheless, many clinicians remain reluctant to honor a request to deactivate a patient's pacemaker. This article describes a case in which a patient was denied her request for pacemaker deactivation. Several reasons for this reluctance are discussed, including historical, practical, and ethical considerations for opposing pacemaker deactivation. Ultimately, however, from an ethical standpoint, pacemaker deactivation is similar to withdrawal of other therapies. Fortunately, a recent expert consensus statement supports a patient's right to have her pacemaker deactivated. Pacemaker deactivation should only be performed after robust informed consent, which must include discussion of risks, benefits, and all viable alternatives based on the patient's values and goals.

Ethical and legal views regarding deactivation of cardiac implantable electrical devices in patients with hypertrophic cardiomyopathy

Little is known about patients' views surrounding the ethical and legal aspects of managing pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) near the end of life. Patients with hypertrophic cardiomyopathy (HC) are at heightened risk of sudden cardiac death and are common recipients of such devices. Patients with HC recruited from the membership of the Hypertrophic Cardiomyopathy Association were surveyed about their clinical histories, advance care planning, legal knowledge, and ethical beliefs relating to the withdrawal of PM and ICD therapy. The mean age of the 546 patients was 49.1 years, 47% were women, and 57% had ICDs. Only 46% of the respondents had completed an advance directive, only 51% had a healthcare proxy, and cardiac implantable electrical devices (CIEDs) were commonly not addressed in either (92% and 58%, respectively). Many patients characterized deactivating PMs or ICDs as euthanasia or physician-assisted suicide (29% for PMs and 17% for ICDs), and >50% expressed uncertainty regarding the legality of device deactivation. Patients viewed deactivation of ICDs and PMs as morally different from other life-sustaining therapies such as mechanical ventilation and dialysis, and these views varied substantially according to the CIED type (p <0.0001). The respondents expressed concerns regarding clinical conflicts related to religion, ethical and legal uncertainty, and informed consent. In conclusion, patients who have, or are eligible to receive, CIEDs might require improved advance care planning and education regarding the ethical and legal options for managing CIEDs at the end of life.

Safety and effectiveness of primary prevention cardioverter defibrillators in octogenarians

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) reduce the rate of sudden cardiac death (SCD) in patients with cardiomyopathy and reduced left ventricular systolic function. It is unclear if this benefit extends to the very elderly patient population.

METHODS

Patients who underwent initial ICD implantation at age 80 or older between January 1995 and April 2010 for primary SCD prevention were identified. Clinical data were collected from the medical record, including periprocedural complications, device type, and therapies delivered.

RESULTS

Three-hundred eighty patients were identified; 84 patients met eligibility criteria. The mean age was 82.68 years; mean follow-up was 34 months. Mean left ventricular ejection fraction was 28.1%. Mortality during follow-up was 17.9%. One- and 5-year survival estimates were 100% and 60%, respectively. Periprocedural complications occurred in 9.4% of patients; serious complications occurred in 4.8% with no periprocedural deaths. Device therapies occurred in 11.9% (n = 10) of patients (9.5% appropriate, n = 8; 2.4% inappropriate, n = 2). Cardiac resynchronization therapy-defibrillator (CRT-D) implantation was associated with prolonged median survival and decreased risk of death (hazard ratio 0.212; 95% confidence interval 0.048-.942, P = 0.042) compared to ICD alone.

CONCLUSIONS

Implantation of primary prevention ICDs in patients 80 years of age or older was associated with a low risk of serious complications and a 5-year survival estimate of 60%. Inappropriate therapies after implantation were uncommon. CRT-D implantation was associated with a decreased risk of death compared to ICD alone. These data suggest that, in selected patients in this age group, ICD implantation is safe and effective.

Device therapy in patients with heart failure and advanced age: too much too late?

Expanding indications for implantable cardiac rhythm devices coupled with the aging of the population have led to a progressive rise in the number of elderly patients referred for device implantation. However, the value of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) in elderly patients remains unproven, in part because few patients over 75 years of age were enrolled in the major device trials. In this article, we summarize the current evidence base regarding the use of device therapy in elderly heart failure patients. We review the efficacy, complications, indications, cost, and current controversies surrounding the use of ICDs and CRT in the geriatric age group. We conclude that reduced benefit coupled with higher complication rates and associated higher costs make it unlikely that the net clinical benefit of an ICD is favorable in most patients over 75 to 80 years of age. Conversely, preliminary data indicate that elderly patients undergoing CRT experience improved quality of life at acceptable cost, suggesting that CRT may be an attractive therapeutic option in appropriately selected patients of advanced age.

Adverse experiences with implantable defibrillators in Oregon hospices

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) improve survival in patients at risk for recurrent, sustained ventricular tachycardia or fibrillation. Unless deactivated, ICDs may deliver unwanted shocks to terminally ill patients near the time of death. This study sought to determine the frequency and nature of adverse experiences with ICDs in hospice programs and what preventative measures the programs had taken.

METHOD

A mailed survey to all 50 Oregon Hospice Programs in August 2008.

RESULTS

42 (84%) of 50 programs participated. In all 36 (86%) of 42 programs reported having taken care of a patient with an ICD in the preceding 4 years. The average number of patients with ICDs per program increased from 2.2 (SD 2.5) in 2005 and 2006 to 3.6 (SD 3.7) in 2007 and 2008. Of the 36 programs who had cared for a patient with an ICD, 31 (86%) reported having some kind of adverse experience. These ranged from unwanted shocks delivered (64%), patient/family distress related to the decision to deactivate the ICD (47%), and time delay in ICD deactivation (42%). Only 16 (38%) programs had policies for managing ICDs and only 19 (43%) routinely screened new patients for ICDs.

DISCUSSION

As patients near the end of their lives, receiving defibrillating shocks may no longer be consistent with their goals of care. Based on the high frequencies of potentially preventable adverse outcomes documented by this study, we propose that hospices routinely screen patients for ICDs and proactively adopt policies to manage them, rather than in response to an adverse event.

Deactivation of implanted cardioverter-defibrillators at the end of life: results of the EHRA survey

This survey assesses the current opinion on and practice of the management of terminally ill patients with implanted cardioverter-defibrillators (ICDs) in 47 large European centres. The principal findings of this survey were that most physicians (62%) from European centres who responded to this survey would consider deactivating ICDs at the patient's end of life. In these circumstances, multiple appropriate ICD shocks may be an indication to deactivate an ICD (83% positive answers). Remote deactivation by a remote monitoring system is not considered appropriate by 68%. Practices of deactivating procedure differ and approach to standardized clinical scenarios is inhomogeneous. Patients are provided with surprisingly little information on the possibility of deactivation of ICDs since this subject is only actively discussed in 4% of centres.

Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: results of a survey of medical and legal professionals and patients

OBJECTIVE

To determine the opinions of medical professionals, legal professionals, and patients regarding the withdrawal of implantable cardioverter-defibrillator (ICD) and pacemaker therapy at the end of life.

PARTICIPANTS AND METHODS

A survey regarding 5 cases that focused on withdrawal of ICD or pacemaker therapy at the end of life was constructed and sent to 5270 medical professionals, legal professionals, and patients. The survey was administered from March 1, 2008, to March 1, 2009.

RESULTS

Of the 5270 recipients of the survey, 658 (12%) responded. In a terminally ill patient requesting that his ICD be turned off, most legal professionals (90% [63/70]), medical professionals (98% [330/336]), and patients (85% [200/236]) agreed the ICD should be turned off. Most legal professionals (89%), medical professionals (87%), and patients (79%) also considered withdrawal of pacemaker therapy in a non-pacemaker-dependent patient appropriate. However, significantly more legal (81%) than medical professionals (58%; P<.001) or patients (68%, P=.02) agreed with turning off a pacemaker in the pacemaker-dependent patient. A similar number of legal professionals thought turning off a device was legal regardless of whether it was an ICD or pacemaker (45% vs 38%; P=.50). However, medical professionals were more likely to perceive turning off an ICD as legal than turning off a pacemaker (85% vs 41%; P<.001).

CONCLUSION

Most respondents thought device therapy should be withdrawn if the patient requested its withdrawal at the end of life. However, opinions of medical professionals and patients tended to be dependent on the type of device, with turning off ICDs being perceived as more acceptable than turning off pacemakers, whereas legal professionals tended to perceive all devices as similar. Thus, education and discussion regarding managing devices at the end of life are important when having end-of-life discussions and making end-of-life decisions to better understand patients' perceptions and expectations.

Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment

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.

End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?

BACKGROUND

Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."

DISCUSSION

Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.

SUMMARY

Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy.