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

The difficult discussion on the deactivation of implantable cardioverter devices at the end of life: a systematic review

Implantable cardioverter defibrillators (ICDs) reliably prevent death due to life-threatening arrhythmias; this may become less relevant in people with more severe heart failure who are reaching the end of life (EOL). This review aimed to explore the ICD deactivation process and identify ethical issues, especially around the initiation of relevant discussions among professionals and patients. Available literature was reviewed using four electronic databases to identify issues that may deter healthcare professionals from having important deactivation discussions and to address considerations for ICD management prior to the EOL. The search resulted in the retainment of 12 studies. Three themes emerged from the data: barriers and facilitators, ethical considerations in clinical practice, and nurse's role. Lack of knowledge, which has been associated with cultural differences, has been found among the barriers, and interdisciplinary education and open communication appeared as facilitators. As clinicians' ethical considerations and fears emerged from the literature, nurses' special role has not been sufficiently supported. Complex care requires facilitation by multidisciplinary teams and education around the device's function regarding EOL issues. Establishing expert consensus statements on advance care planning might help define the distinct roles of each healthcare practitioner involved. Further research is needed in addressing the identified gaps.

Communication regarding the deactivation of implantable cardioverter-defibrillators: A scoping review and narrative summary of current interventions

OBJECTIVES

Communication about deactivation of implantable cardioverter-defibrillator (ICD) therapy at end-of-life (EoL) is a recognised issue within clinical practice. The aim of this scoping review was to explore and map the current literature in this field, with a focus on papers which implemented interventional studies.

METHODS

Systematic searches of six major databases were conducted. Citations were included by four researchers according to selection criteria. Key demographic data and prespecified themes in relation to communication of ICD deactivation at EoL were extracted.

RESULTS

The search found 6197 texts of which 63 were included: 39 quantitative, 14 qualitative and 10 mixed-methods. Surveys were predominantly used to gather data (n = 34), followed by interviews (n = 18) and retrospective reviews of patient records (n = 18).

CONCLUSIONS

Several key gaps in the literature warrant further research. These include who is responsible for initiating ICD deactivation discussions, how clinicians should initiate and conduct these discussions, when ICD deactivations should be occurring, and family perspectives. Adequately explored themes include patient and clinician knowledge and attitudes regarding ICD deactivation at EoL.

PRACTICAL IMPLICATIONS

Facilities treating patients with ICDs at EoL should consider ongoing quality improvement projects aimed at clinician education and protocol changes to improve communication surrounding EoL ICD deactivation.

'Life with a device': the octogenarians' experiences with an implantable cardioverter-defibrillator-a qualitative study

AIMS

Implantable cardioverter-defibrillator (ICD) treatment has expanded due to its effectiveness. However, there are concerns about complications, and use in the most elderly has been questioned. There is scarce data on qualitative aspects regarding experiences of living with an ICD among patients above the age of 80 years. The aim of this study was to explore octogenarians' experience, knowledge, and attitude of living with an ICD.

METHOD AND RESULTS

We used semi-structured interviews to collect data from 20 patients, aged 80-89 years (90% men). The data were then structured and analysed through deductive thematic analysis network approach using the ATLAS.ti v.8.4 software. The framework of the analysis was based on the Successful Aging Theory. Three main themes emerged regarding the patients' experiences: Life goes on; Their Health, The Janus-Faced Device; Their attitudes, and Mind the gap; Their knowledge. None of the octogenarians regretted receiving their ICD, instead, they presented with feelings such as gratitude towards the device. However, a lack of knowledge about the devices was expressed, which can be a risk for potential complications, in turn causing suffering and unnecessary concerns.

CONCLUSION

Overall, the ICD did not pose a threat towards successful ageing. It was mainly considered a life-saving device. However, the lack of knowledge might hinder informed choices close to death and contribute to ethical dilemmas when deactivation of the ICD is a reasonable option.

Moral Distress at the End of a Life: When Family and Clinicians Do Not Agree on Implantable Cardioverter-Defibrillator Deactivation

A 63-year-old man with end-stage ischemic cardiomyopathy presented with incessant ventricular tachycardia. He had been hospitalized multiple times in the past year for severe heart failure. As he approached end of life and was regularly receiving defibrillator shocks, his care team recommended deactivation of his implantable cardioverter-defibrillator. However, his family did not wish to allow deactivation, reporting a religious obligation to prolong his life, regardless of the risk of suffering. The patient was unable to adequately participate in the decision-making process. An implantable cardioverter-defibrillator can serve to avoid sudden death but may lead to a prolonged death from heart failure. This possibility forces the examination of values regarding prolongation of life, sometimes producing disagreement among stakeholders. Although ethical consensus holds that defibrillator deactivation is legal and ethical, disagreements about life prolongation may complicate decision making. The ethical, technical, and medical complexity involved in this case speaks to the need for clear, prospective communication involving the patient, the patient's family, and members of the care team.

Patients' perception of implantable cardioverter defibrillator deactivation at the end of life

BACKGROUND

Individualised care at the end of life requires professional understanding of the patient's perception of implantable cardioverter defibrillator deactivation.

AIM

The aim was to evaluate the evidence on patients' perception of implantable cardioverter defibrillator deactivation at end of life.

DESIGN

Systematic narrative review of empirical studies was published during 2008-2014.

DATA SOURCES

Data were collected from six databases, citations from relevant articles and expert recommendations.

RESULTS

In all, 18 studies included with collective population of n = 5810. Concept mapping highlighted three themes: (1) Diverse preferences regarding discussion and deactivation. Deactivation was rarely discussed pre-implantation, with some studies demonstrating patients' reluctance to discuss implantable cardioverter defibrillator deactivation at any stage. Two studies found the majority of patients valued such discussions. Diversity was reflected in patients' willingness to deactivate, ranging from 12% (n = 9) in Irish cohort to 79% (n = 195) in Dutch study. (2) Ethical and legal considerations were predominant in Canadian and American literature as patients wanted to contribute but felt the decision should be a doctor's responsibility. Advance directives were uncommon in Europe, and where they existed the implantable cardioverter defibrillator was not mentioned. (3) 'Living in the now' was evident as despite deteriorating symptoms many patients maintained a positive outlook and anticipated surviving more than 10 years. Several studies asserted living longer was more important than quality of life.

CONCLUSION

Patients regard the implantable cardioverter defibrillator as a complex and solely beneficial device, with little insight regarding its potential impact on a peaceful death. This review confirms the need for professionals to discuss with patients and families implantable cardioverter defibrillator functionality and deactivation at appropriate opportunities.

[Guidelines on the management of implantable cardioverter defibrillators at the end of life]

This article is a joint document of the Spanish Society of Geriatrics and Gerontology, the Spanish Society of Palliative Care and the Section of Geriatric Cardiology of the Spanish Society of Cardiology. Its aim is to address the huge gap that exists in Spain with regard to the management of implantable cardioverter defibrillators (ICDs) in the final stages of life. It is increasingly common to find patients carrying these devices that are in the terminal stage of an advanced disease. This occurs in patients with advanced heart disease and subsequent heart failure refractory to treatment but also in a patient with an ICD who develops cancer disease, organ failure or other neurodegenerative diseases with poor short-term prognosis. The vast majority of these patients are over 65, so the paper focuses particularly on the elderly who are in this situation, but the decision-making process is similar in younger patients with ICDs who are in the final phase of their life.

Patients' perspective on deactivation of the implantable cardioverter-defibrillator near the end of life

Recent guidelines have emphasized the importance of discussing the issue of deactivation near the end of life with patients with an implantable cardioverter-defibrillator (ICD). Few studies have examined the patient perspective and patients' wishes. We examined patients' knowledge and wishes for information; and the prevalence and correlates of a favorable attitude toward deactivation. Three cohorts of ICD patients (n = 440) extracted from our institutional database were asked to complete a survey that included a vignette about deactivation near the end of life. Of the 440 patients approached, 294 (67%) completed the survey. Most patients (68%) were aware that it is possible to turn the ICD off, and 95% believed it is important to inform patients about the possibility. Of the patients completing the survey, 84% indicated a choice for or against deactivation. Psychological morbidity was not associated with a response in favor or against deactivation (p >0.05 for all). The wish for a worthy death near the end of life was an independent associate of a favorable attitude toward deactivation (odds ratio 2.14, 95% confidence interval 1.49 to 3.06, p <0.0001), adjusting for the importance of avoiding shock-related pain, anxiety, and poor quality of life and other potential confounders. In conclusion, most ICD patients seemed to favor device deactivation at the end of life, primarily owing to the wish for a worthy death. This finding indicates that patients have thought about the issue of deactivation near the end of life and might welcome the chance to discuss it with their physician.

Life-saving devices reach the end of life with heart failure

The new millennium has seen a dramatic increase in use of potentially life-prolonging devices such as implantable cardioverter-defibrillators (ICDs) and ventricular assist devices (VADs) among patients with advanced heart failure. Most patients who receive these devices will have them in place when they die. Clinicians who care for these patients must commit through the entire course of therapy, including the end-of-life. Discussions about device deactivation should be the standard of care and this discussion should take place prior to implantation, during annual heart failure reviews, after major milestones, and when the end-of-life appears to be approaching. Turning off ICDs and turning off VADs in response to patient or proxy requests are legally the same although they may be perceived differently, as disconnection of the VAD is more likely to cause immediate death. This article discusses the evidence around device deactivation at the end-of-life and offers suggestions for improvement.

Deactivation of pacemakers and implantable cardioverter-defibrillators

Cardiac implantable electrical devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs), are the most effective treatment for life-threatening arrhythmias. Patients or their surrogates may request device deactivation to avoid prolongation of the dying process or in other settings, such as after device-related complications or with changes in health care goals. Despite published guidelines outlining theoretical and practical aspects of this common clinical scenario, significant uncertainty remains for both patients and health care providers regarding the ethical and legal status of CIED deactivation. This review outlines the ethical and legal principles supporting CIED deactivation, centered upon patient autonomy and authority over their own medical treatment. The empirical literature describing stakeholder views and experiences surrounding CIED deactivation is described, along with implications of these studies for future research surrounding the care of patients with CIEDs.

The Ethics of Deactivating a Pacemaker in a Pacing-Dependent Patient

The decision to deactivate a pacemaker in a pacing-dependent patient is troubling for some health professionals who may regard such interventions as hastening death and therefore ethically impermissible. This may be especially concerning in situations where a patient is unable to clearly state what their preferences may be and the decision—were it to be made—will almost certainly result in the patient’s immediate death. In this discussion, we reflect on some of the ethical aspects that arise when JP, a 75-year-old woman who is pacing dependent, suffers a significant brain injury, and the family request that her pacemaker be deactivated. Taking into account the clinical reality of her situation, the united wishes and loving concern of her husband and family, and their substituted judgment regarding her likely preferences, we claim that the decision to deactivate her pacemaker was ethically sound.

The deactivation of implantable cardioverter-defibrillators: medical, ethical, practical, and legal considerations

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) cannot prevent death from progressive heart failure or non-cardiac disease. Patients with ICDs may receive defibrillation therapy from their devices in the last days of their lives, when such therapy does not accord with the goal of palliative treatment, but rather lowers these patients' quality of life and compromises their dignity.

METHODS

We present a case report and a selective review of pertinent literature retrieved by a PubMed search, including two up-to-date consensus documents.

RESULTS

One-third to two-thirds of all ICD patients receive defibrillation therapy in the final days of their lives. Patients and their physicians rarely discuss deactivating the ICD. The ethical aspects of such decisions need to be considered. As a practical matter, it is possible to deactivate certain types of electrotherapy selectively, while leaving others active. There are logistical considerations as well.

CONCLUSION

Automatic defibrillation therapy in a terminally ill patient with an ICD is painful and distressing, serves no medical purpose, and should be avoided. This issue should be discussed with ICD patients and their families. Institutions caring for terminally ill patients, as well as cardiology units where ICD patients are treated, should develop ethically and legally well-founded protocols for dealing with the question of ICD deactivation.

ICD Deactivation

Implanted cardioverter defibrillators (ICDs) are an essential part of the management for patients at risk for life threatening arrhythmias. Despite new technologies, all patients ultimately will reach the end of their lives, either because of underlying cardiac disease or another terminal illness. Having an ICD at the end of life may deny a patient the chance of sudden cardiac death and result in a slower terminal disease and pain and anxiety due to shocks from their device. The purpose of this article is to present a focused literature review on the barriers surrounding deactivation of ICDs and to summarize the recommendations of the Heart Rhythm Society Consensus Statement on the management of ICDs in patients nearing end of life or requesting withdrawal of therapy.

Ethical challenges with deactivation of durable mechanical circulatory support at the end of life: left ventricular assist devices and total artificial hearts

Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) are surgically implanted as permanent treatment of unrecoverable heart failure. Both LVADs and TAHs are durable mechanical circulatory support (MCS) devices that can prolong patient survival but also alter end-of-life trajectory. The permissibility of discontinuing assisted circulation is controversial because device deactivation is a life-ending intervention. Durable MCS is intended to successfully replace native physiological functions in heart disease. We posit that the presence of new lethal pathophysiology (ie, a self-perpetuating cascade of abnormal physiological processes causing death) is a central element in evaluating the permissibility of deactivating an LVAD or a TAH. Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions replaced by an LVAD or a TAH. Examples of such lethal conditions include irreversible coma, circulatory shock, overwhelming infections, multiple organ failure, refractory hypoxia, or catastrophic device failure. In all other situations, deactivating the LVAD/TAH is itself the lethal pathophysiology and the proximate cause of death. We postulate that the onset of new lethal pathophysiology is the determinant factor in judging the permissibility of the life-ending discontinuation of a durable MCS.

Deactivation of implantable cardioverter defibrillators in terminal illness and end of life care

Cardiology professional societies have recommended that patients with cardiovascular implantable electronic devices complete advance directives (ADs). However, physicians rarely discuss end of life handling of implantable cardioverter defibrillators (ICDs), and standard AD forms do not address the presence of ICDs. We conducted a telephone survey of 278 patients with an ICD from a large, academic hospital. The average period since implantation was 5.15 years. More than 1/3 (38%) had been shocked, with a mean of 4.69 shocks. More than 1/2 had executed an AD, but only 3 had included a plan for their ICD. Most subjects (86%) had never considered what to do with their ICD if they had a serious illness and were unlikely to survive. When asked about ICD deactivation in an end of life situation, 42% said it would depend, 28% favored deactivation, and 11% would not deactivate. One quarter (26%) thought ICD deactivation was a form of assisted suicide, 22% thought a do not resuscitate order did not mean that the ICD should be deactivated, and 46% responded that the ICD should not be automatically deactivated in hospice. The answers did not correlate with any demographic factors. Almost all (95%) agreed that patients should have the opportunity to execute an AD that directs handing of an ICD. When asked who should be responsible for discussing this device for an AD, 31% said electrophysiologists, 45% said general cardiologists, and 14% said primary care physicians. In conclusion, the results of the present study highlight the lack of consensus among patients with an ICD on the issue of deactivation at the end of a patient's life. These findings suggest cardiologists should discuss end of life care and device deactivation with their patients with an ICD.

Cardiac implantable electrical devices: bioethics and management issues near the end of life

Cardiac implantable electrical devices (CIEDs) are extremely sophisticated modern devices that provide patients with many beneficial effects, including increased survival and enhanced quality of life. CIEDs, however, may complicate and unnecessarily prolong the process of dying from terminal illnesses. A rational plan for CIED deactivation near the end of life should therefore be carefully drawn up well in advance by the patient in concert with loved ones and treating physicians.