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Pottash M, Rao A. The Complex Ethical and Moral Experience of Left Ventricular Assist Device Deactivation. J Pain Symptom Manage 2024; 67:274-278. [PMID: 37984719 DOI: 10.1016/j.jpainsymman.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The left ventricular assist device (LVAD) is a fully implantable cardiac replacement device that can complicate the process of dying. We present a case of a patient who attempted to deactivate the LVAD without the support of his medical team. This action was understood as a "suicide attempt" though when the patient was later felt to be dying, LVAD deactivation proceeded without reference to psychiatric illness. To understand this case, we discuss the ethics of LVAD deactivation in the dying process. We then explore the experience of clinicians and the public encountering this unique technology across clinical contexts. We herein present a novel and possibly controversial analysis of the moral complexities of LVAD deactivation and suggest that clinicians be transparent about these complexities with patients and families.
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Affiliation(s)
- Michael Pottash
- Division of Palliative Medicine, Department of Medicine (M.P., A.R.), MedStar Washington Hospital Center, Washington, DC, USA; Georgetown University School of Medicine (M.P., A.R.), Washington, DC, USA.
| | - Anirudh Rao
- Division of Palliative Medicine, Department of Medicine (M.P., A.R.), MedStar Washington Hospital Center, Washington, DC, USA; Georgetown University School of Medicine (M.P., A.R.), Washington, DC, USA
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2
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Adams DM. Clinical Ethics and Professional Integrity: A Comment on the ASBH Code. HEC Forum 2023:10.1007/s10730-023-09516-z. [PMID: 38127244 DOI: 10.1007/s10730-023-09516-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 12/23/2023]
Abstract
The Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants instructs clinical ethics consultants to preserve their professional integrity by "not engaging in activities that involve giving an ethical justification or stamp of approval to practices they believe are inconsistent with agreed-upon standards" (ASBH, 2014, p. 2). This instruction reflects a larger model of how to address value uncertainty and moral conflict in healthcare, and it brings up some intriguing and as yet unanswered questions-ones that the drafters of the Code, and the profession more broadly, should seek to address in upcoming revisions. The objective of this article is to raise these questions as a way of urging greater clarification of the Code's overall approach to professional integrity, its meaning, and implications.
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Affiliation(s)
- David M Adams
- Department of Philosophy, California State Polytechnic University, Pomona, CA, USA.
- Pomona Valley Hospital Medical Center, Pomona, CA, USA.
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3
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Taj J, Taylor EP. End-Stage/Advanced Heart Failure: Geriatric Palliative Care Considerations. Clin Geriatr Med 2023; 39:369-378. [PMID: 37385689 DOI: 10.1016/j.cger.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Heart failure remains a condition with high morbidity and mortality affecting 23 million people globally with a cost burden equivalent to 5.4% of the total health care budget in the United States. These costs include repeated hospitalizations as the disease advances and care that may not align with individual wishes and values. The coincidence of comorbid conditions with advanced heart failure poses significant challenges in the geriatric population. Advance care planning, medication education, and minimizing polypharmacy are primary palliative opportunities leading to specialist palliative care such as symptom management at end of life and timing of referral to hospice.
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Affiliation(s)
- Jabeen Taj
- Division of Hospice and Palliative Medicine, Department of Family Medicine, Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road, Atlanta, GA 30322, USA.
| | - Emily Pinto Taylor
- Division of General Internal Medicine, Department of Family Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Drive Southeast, Atlanta, GA 30303, USA; Division of Hospice and Palliative Medicine, Department of Family Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Drive Southeast, Atlanta, GA 30303, USA
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4
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Berthiau D, Pagès L, Foureur N. [Can we remove a pacemaker in the name of unreasonable obstinacy? The story of Odette]. Med Sci (Paris) 2023; 39:177-180. [PMID: 36799755 DOI: 10.1051/medsci/2023012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
« Les humanités en santé : histoire de cas » sont coor- données par Claire Crignon, professeure d’histoire et de philosophie des sciences à l’université de Lorraine, qui a créé le master « humanités biomédicales » à Sorbonne université.
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Affiliation(s)
- Denis Berthiau
- Centre d'éthique clinique de l'AP-HP, hôpital Cochin, 27 rue du faubourg Saint-Jacques 75679 Paris cedex 14, France
| | - Louise Pagès
- Centre d'éthique clinique de l'AP-HP, hôpital Cochin, 27 rue du faubourg Saint-Jacques 75679 Paris cedex 14, France
| | - Nicolas Foureur
- Centre d'éthique clinique de l'AP-HP, hôpital Cochin, 27 rue du faubourg Saint-Jacques 75679 Paris cedex 14, France
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5
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Landry-Hould F, Mondésert B, Day AG, Ross HJ, Brouillette J, Clarke B, Zieroth S, Toma M, Parent MC, Fowler RA, You JJ, Ducharme A. Characteristics of Clinicians Are Associated With Their Beliefs About ICD Deactivation: Insight From the DECIDE-HF Study. CJC Open 2021; 3:994-1001. [PMID: 34505038 PMCID: PMC8413241 DOI: 10.1016/j.cjco.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022] Open
Abstract
Background Discussing goals of care with heart failure patients is recommended but is not done systematically, due to factors such as time and personal beliefs. A recent survey showed that one-fifth of clinicians believe that implantable cardioverter defibrillator deactivation (ICDD) is unethical or constitutes physician-assisted suicide. We investigated whether individuals’ characteristics are associated with these beliefs. Methods The Decision-Making About Goals of Care for Hospitalized Patients With Heart Failure (DECIDE-HF) survey was given to healthcare providers at 9 hospitals to assess their perceived barriers to goals-of-care discussions. The association between respondent characteristics and their beliefs was examined using 2 adjusted logistic regression models. Results We included 760 clinicians (459 nurses, 94 fellows, and 207 cardiologists). The responses varied among professions, with the belief that ICDD is unethical considered to be important barrier by nurses (24%), fellows (10%), and staff (7%); P < 0.001). After adjusting for site, spirituality being more important in life (odds ratio [OR]: 2.21; 95% confidence interval [CI]:1.37-3.56; P = 0.001, compared to less important), region of training (Asia [OR: 5.88; 95% CI: 2.12-16.31; P = 0.001] and Middle East [OR: 5.55; 95% CI:1.57-19.63; P = 0.008] compared to Canada), and years in practice (OR: 1.32; 95% CI: 1.07-1.63; P = 0.01 per decade) influenced beliefs about ICDD being unethical, with similar results for the belief that ICDD represents physician-assisted suicide. Conclusions Sociocultural factors, region of training, and profession influence clinicians’ beliefs about ICDD being unethical and representing physician-assisted suicide. These factors and beliefs must be acknowledged when facing the delicate issue of end-of-life discussion.
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Affiliation(s)
- Florence Landry-Hould
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Blandine Mondésert
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Heather J Ross
- Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Brouillette
- Departments of Psychiatry and Addictology, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Brian Clarke
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shelley Zieroth
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mustafa Toma
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marie-Claude Parent
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Robert A Fowler
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John J You
- Department of Medicine, Division of General Internal and Hospitalist Medicine, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
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6
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Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource Allocation and Patient Triage During the COVID-19 Pandemic: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 76:85-92. [PMID: 32407772 PMCID: PMC7213960 DOI: 10.1016/j.jacc.2020.05.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
The COVID-19 pandemic and its sequelae have created scenarios of scarce medical resources, leading to the prospect that health care systems have faced or will face difficult decisions about triage, allocation, and reallocation. These decisions should be guided by ethical principles and values, should not be made before crisis standards have been declared by authorities, and, in most cases, will not be made by bedside clinicians. Do not attempt resuscitation and withholding and withdrawing decisions should be made according to standard determination of medical appropriateness and futility, but there are unique considerations during a pandemic. Transparent and clear communication is crucial, coupled with dedication to provide the best possible care to patients, including palliative care. As medical knowledge about COVID-19 grows, more will be known about prognostic factors that can guide these difficult decisions. Difficult decisions about triage and allocation have arisen in the COVID-19 pandemic. In a crisis, autonomy may become subordinate to maximize the number of lives saved. Fairness involves equal access to scarce resources, ignoring factors unrelated to prognosis and maximizing benefit. Transparent communication and palliative care are central to providing the best possible care to patients.
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Affiliation(s)
- James N Kirkpatrick
- Division of Cardiology and Department of Bioethics and Humanities, University of Washington, Seattle, Washington.
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Program for Biomedical Ethics, Yale University, New Haven, Connecticut
| | - Savitri Fedson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Section of Cardiology, Michael E DeBakey VA Medical Center, Houston, Texas
| | | | - Sarah J Goodlin
- Department of Geriatrics and Palliative Medicine, VAPORHCS, Oregon Health Sciences University, Patient-Centered Education and Research, Portland, Oregon
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7
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Brady DR. Planning for Deactivation of Implantable Cardioverter Defibrillators at the End of Life in Patients With Heart Failure. Crit Care Nurse 2018; 36:24-31. [PMID: 27908943 DOI: 10.4037/ccn2016362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) may be burdensome in end-stage heart failure. At the end of life, as many as one-fifth to one-third of patients experience an ICD shock. Critical care nurses should be aware of the potential burden of these shocks at the end of life as well as the ethics and organizational policies surrounding ICD deactivation. This literature review examines the issues surrounding ICD therapy at the end of life. Based on this author's findings, recommendations for discussing and implementing ICD deactivation are offered. Health care organizations should have clear policies addressing ICD deactivation to provide for seamless integration of palliative care services throughout the course of heart failure. These policies should empower nurses to activate resources in a timely manner and should clearly outline processes for ICD deactivation.
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Affiliation(s)
- Destiny R Brady
- Destiny R. Brady teaches critical care nursing at Saint Anselm College in Manchester, New Hampshire.
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8
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Practical and ethical considerations in the management of pacemaker and implantable cardiac defibrillator devices in terminally ill patients. Proc (Bayl Univ Med Cent) 2017; 30:157-160. [PMID: 28405065 DOI: 10.1080/08998280.2017.11929566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
More than 4.5 million people worldwide live with an implanted pacemaker, including >3 million in the USA alone. Also, >0.8 million people in the USA have an implantable cardioverter defibrillator (ICD). Knowing the principles of managing these devices towards the end of life is important, as the interruption of their function may have serious consequences. This article provides health care providers who are not specialized in cardiac electrophysiology with an introduction to the general principles of management of pacemakers or ICD devices towards the end of life, with a suggested algorithm for approaching this process. Also discussed are pertinent ethical and practical considerations in deciding on and implementing a management strategy for these devices during terminal illnesses.
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9
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Hutchison K, Sparrow R. Ethics and the cardiac pacemaker: more than just end-of-life issues. Europace 2017; 20:739-746. [DOI: 10.1093/europace/eux019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 03/30/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katrina Hutchison
- Philosophy Program, ARC Centre of Excellence for Electromaterials Science, Monash University, Wellington Road, Melbourne, VIC 3800, Australia
| | - Robert Sparrow
- Philosophy Program, Centre for Human Bioethics, ARC Centre of Excellence for Electromaterials Science, Monash University, Wellington Road, Melbourne, VIC 3800, Australia
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11
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Lantos JD. Reason, Emotion, and Implanted Devices. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:1-2. [PMID: 27366834 DOI: 10.1080/15265161.2016.1199608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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12
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Karches KE, Sulmasy DP. Ethical considerations for turning off pacemakers and defibrillators. Card Electrophysiol Clin 2015; 7:547-55. [PMID: 26304534 DOI: 10.1016/j.ccep.2015.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The 2010 guidelines regarding management of cardiovascular implantable electronic devices (CIEDs) conclude that patient requests to deactivate these devices at the end of life should be honored. Nevertheless, many clinicians and patients report feeling uncomfortable discontinuing such therapies, particularly pacemakers. If the principles of clinical ethics are followed, turning off CIEDs at the end of life is morally permissible. Clinicians managing CIEDs should discuss the option of deactivation with the patient at the time of implantation and be prepared to reopen the question as warranted by the patient's clinical course and respect for the patient's authentic values.
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Affiliation(s)
- Kyle E Karches
- Department of Medicine, The University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Daniel P Sulmasy
- Department of Medicine and Divinity School, The University of Chicago Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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13
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Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN. Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:917-24. [PMID: 25683098 DOI: 10.1111/pace.12614] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 01/30/2015] [Accepted: 02/09/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unilateral do-not-resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. We investigated whether electrophysiology practitioners believe medical futility justifies unilateral implantable cardioverter defibrillator (ICD) deactivation. METHODS AND RESULTS Email invitations to take an online survey were sent to 1,894 electrophysiology practitioners. A total of 384 responses were collected (response rate 20.6%). Though the sample included respondents from Europe, Asia, Australia, South America, and Africa, the majority were from North America (78%), were academically affiliated (64%), and practiced in an urban setting (67.8%). Deactivation of ICD shock function in agreement with patient wishes and a preexisting DNR were not considered physician-assisted suicide (93.2%, 358/384). However, a majority of the sample responded that it was not ethical/moral for doctors to deactivate ICDs against patients' wishes (77.1%, 296/384) or against family/surrogates' wishes (72.4%, 278/384), even in the context of medical futility. A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding cardiopulmonary resuscitation or external defibrillation in a code (72.7%, 277/381), but was different than deactivating pacing in a pacemaker-dependent patient (82.8%, 318/384). In the classification of interventions, a plurality (43.0%, 165/383) regarded ICDs to be unlike any other intervention. Concerning pacemakers, 50% (191/382) considered them to be like dialysis (a therapy that keeps patients alive). CONCLUSIONS This international sample of electrophysiology practitioners considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not.
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Swetz KM, Kamal AH, Matlock DD, Dose AM, Borkenhagen LS, Kimeu AK, Dunlay SM, Feely MA. Preparedness planning before mechanical circulatory support: a "how-to" guide for palliative medicine clinicians. J Pain Symptom Manage 2014; 47:926-935.e6. [PMID: 24094703 DOI: 10.1016/j.jpainsymman.2013.06.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/29/2013] [Accepted: 06/14/2013] [Indexed: 11/29/2022]
Abstract
The role of palliative medicine in the care of patients with advanced heart failure, including those who receive mechanical circulatory support, has grown dramatically in the last decade. Previous literature has suggested that palliative medicine providers are well poised to assist cardiologists, cardiothoracic surgeons, and the multidisciplinary cardiovascular team with promotion of informed consent and initial and iterative discussions regarding goals of care. Although preparedness planning has been described previously, the actual methods that can be used to complete a preparedness plan have not been well defined. Herein, we outline several key aspects of this approach and detail strategies for engaging patients who are receiving mechanical circulatory support in preparedness planning.
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Affiliation(s)
- Keith M Swetz
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | | | - Ann Marie Dose
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn S Borkenhagen
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ashley K Kimeu
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon M Dunlay
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Molly A Feely
- Division of General Internal Medicine, Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Buchhalter LC, Ottenberg AL, Webster TL, Swetz KM, Hayes DL, Mueller PS. Features and outcomes of patients who underwent cardiac device deactivation. JAMA Intern Med 2014; 174:80-5. [PMID: 24276835 PMCID: PMC4266591 DOI: 10.1001/jamainternmed.2013.11564] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Little is known about patients who undergo cardiovascular implantable electronic device deactivation. OBJECTIVE To describe features and outcomes of patients who underwent cardiovascular implantable electronic device deactivation. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of medical records of 150 patients at a tertiary academic medical center (Mayo Clinic, Rochester, Minnesota). EXPOSURE Cardiovascular implantable electronic device deactivation. MAIN OUTCOMES AND MEASURES Demographic and clinical data and information regarding advance directives, ethics consultations, palliative medicine consultations, and cardiovascular implantable electronic device deactivations. RESULTS Of the 150 patients (median age, 79 years; 67% were male), 149 (99%) had poor or terminal prognoses. Overall, 118 patients (79%) underwent deactivation of tachycardia therapies only, and 32 (21%) underwent deactivation of bradycardia therapies with or without tachycardia therapies (6 patients [4%] were pacemaker-dependent). Half of the deactivation requests (51%) were made by surrogates. A majority of deactivations (55%) were carried out by nurses. Although 85 patients (57%) had advance directives, only 1 mentioned the device in the directive. Ethics consultations occurred in 3 patients (2%) and palliative medicine consultations in 64 (43%). The proportions of patients who died within 1 month of device deactivation were similar for those who underwent deactivation of tachycardia therapies only and those who underwent deactivation of bradycardia therapies with or without tachycardia therapies (85% vs 94%; P = .37). CONCLUSIONS AND RELEVANCE Most requests for cardiovascular implantable electronic device deactivation were for implantable cardioverter-defibrillator-delivered tachycardia therapies only. Many of these requests were made by surrogates. Advance directives executed by patients with these devices rarely addressed device management. Regardless of device therapy, most patients died shortly after device deactivation. Hence, a device deactivation decision may reflect the seriousness of a given patient's underlying illness. Patients with devices should engage in advance care planning to ensure that future care is consistent with their preferences.
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Affiliation(s)
| | | | - Tracy L Webster
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota4Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David L Hayes
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Paul S Mueller
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota4Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Pasalic D, Tajouri TH, Ottenberg AL, Mueller PS. The prevalence and contents of advance directives in patients with pacemakers. Pacing Clin Electrophysiol 2013; 37:473-80. [PMID: 24215172 DOI: 10.1111/pace.12287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/05/2013] [Accepted: 09/02/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the use of advance directives (ADs) in patients who have implantable cardiac pacemakers (PMs). METHODS We conducted a retrospective review of the medical records of residents of Olmsted County, Minnesota, who underwent implantation of a cardiac PM at Mayo Clinic (Rochester, Minnesota) during 2006 and 2007, and determined the prevalence and contents of ADs in these patients. RESULTS During the study period, 205 residents of Olmsted County (men, 53%) underwent PM implantation (mean age [standard deviation] at implantation, 77 [15] years). Overall, 120 patients (59%) had ADs. Of these, 63 ADs (53%) were executed more than 12 months before and 33 (28%) were executed after PM implantation. Many patients specifically mentioned life-prolonging treatments in their ADs: cardiopulmonary resuscitation, 76 (63%); mechanical ventilation, 56 (47%); and hemodialysis, 31 (26%). Pain control was mentioned in 79 ADs (66%) and comfort measures were mentioned in 42 ADs (35%). Furthermore, the AD of many patients contained a general statement about end-of-life care (e.g., no "heroic measures"). However, only one AD (1%) specifically addressed the end-of-life management of the PM. CONCLUSIONS More than half of the patients with PMs in our study had executed an AD, but only one patient specifically mentioned her PM in her AD. These results suggest that patients with PMs should be encouraged to execute ADs and specifically address end-of-life device management in their ADs. Doing so may prevent end-of-life ethical dilemmas related to PM management.
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Affiliation(s)
- Dario Pasalic
- Mayo Medical School, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
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Kay GN, Pelosi F. An Ethical Analysis of Withdrawal of Therapy in Patients with Implantable Cardiac Electronic Devices: Application of a Novel Decision Algorithm. LINACRE QUARTERLY 2013; 80:308-316. [PMID: 30083010 DOI: 10.1179/2050854913y.0000000005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Patients with cardiovascular implantable electronic devices (CIEDs), which include pacemakers and implantable cardioverter-defibrillators (ICDs), may request deactivation of their devices as they approach the end of life. The Heart Rhythm Society (2010) has stated that "ethically, and legally, there are no differences between refusing CIED therapy and requesting withdrawal of CIED therapy." On the basis of the principle that there is no ethical distinction between withholding and withdrawing treatment, this professional organization has suggested that both the antibradycardia and antitachycardia features of these devices may be disabled at the patient's request. We argue that disabling ICD shocks is analogs to a do-not-resuscitate order and is ethically permissible whereas withdrawing pacing from a pacemaker-dependent patient is an act of intentionally hastening death and not morally licit.
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Affiliation(s)
- G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Frank Pelosi
- Division of Cardiovascular Medicine, Cardiac Electrophysiology Section, University of Michigan Health System, Ann Arbor, Michigan, USA
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18
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Ethical considerations for discontinuing pacemakers and automatic implantable cardiac defibrillators at the end-of-life. Curr Opin Anaesthesiol 2013; 26:171-5. [DOI: 10.1097/aco.0b013e32835e8349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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