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Portig I, Hofacker E, Sommer P, Volberg C, Seifart C. Cardiologists' perspective on termination of pacemaker therapy-an anonymous survey among cardiologists in Germany. Clin Res Cardiol 2024:10.1007/s00392-024-02525-z. [PMID: 39222279 DOI: 10.1007/s00392-024-02525-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/14/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The patient's right to refuse pacemaker therapy is mentioned in the relevant European consensus statement but additional information is only available on deactivation of implantable cardioverter deactivator and not on other cardiac implantable electronic devices such as pacemakers. Therefore, we were interested in opinions, concerns and attitudes of cardiologists, who are the primary contact persons for such requests, since the number of patients asking for withdrawal of pacemaker therapy is likely to increase leaving cardiologists and healthcare professionals with a difficult medical but also ethical problem. METHODS An anonymous questionnaire was sent to all German cardiology departments (N = 288). RESULTS 48% of cardiology departments responded by sending back 247 completed questionnaires. Most participating cardiologists were experienced when considering the duration of their professional activity. Almost all of the respondents regularly perform check-ups of pacemakers. The majority of cardiologists answering our questionnaire were prepared to deactivate a pacemaker upon patients' request, and have done so. In pacemaker dependency, however, the willingness to withdraw decreases, even if death is imminent, for fear of causing distressing symptoms, sense of being responsible for patients possible immediate death, or fear of legal consequences. CONCLUSIONS The survey could clearly show that uncertainties remain among cardiologists dealing with a patient's wish for withdrawal, especially in cases of pacemaker dependency. We suggest that official statements of cardiologic societies in Europe are issued to clarify ethical, legal and practical aspects of pacemaker withdrawal. TRIAL REGISTRATION Registered in the German Clinical Trials Register (DRKS00026168) on 30.08.2021.
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Affiliation(s)
- Irene Portig
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Elena Hofacker
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, University Hospital of Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Christian Volberg
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, Baldingerstraße, 35043, Marburg, Germany.
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University of Marburg, Baldingerstraße, 35043, Marburg, Germany.
| | - Carola Seifart
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, Baldingerstraße, 35043, Marburg, Germany
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Portig I, Karaaslan E, Hofacker E, Volberg C, Seifart C. Patients' Perspective on Termination of Pacemaker Therapy-A Cross-Sectional Anonymous Survey among Patients Carrying a Pacemaker in Germany. Healthcare (Basel) 2023; 11:2896. [PMID: 37958040 PMCID: PMC10649284 DOI: 10.3390/healthcare11212896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE To determine the opinions of patients regarding the withdrawal of pacemaker therapy. PARTICIPANTS AND METHODS A cross-sectional anonymous questionnaire was administered to patients visiting an outpatient cardiologic clinic for routine follow-up visits of pacemaker therapy or patients carrying a pacemaker admitted to a hospital between 2021 and 2022. RESULTS Three-hundred and forty patients answered the questionnaire. A total of 56% of the participants were male. The mean age was 81 years. The majority of respondents were very comfortable with their PM and felt well informed, with one exception: more than half of respondents were missing information on withdrawal of pacemaker therapy. Almost two-thirds wanted to decide for themselves if their pacemaker therapy was withdrawn regardless of whether they were ill or healthy. Almost 60% of patients would like the pacemaker to be turned off when dying. Women expressed this wish significantly more often than men. CONCLUSION Our survey shows that patients prefer to be informed on issues regarding the withdrawal of pacemakers as early as preimplantation. Also, patients would like to be involved in decisions that have to be made at the end of life, including decisions on withdrawal. Offers of conversations about this important issue should include information on special features of the patient's pacemaker, e.g., the absence or presence of pacemaker dependency. Knowledge about the pacemaker's functionality may prevent distress among individuals nearing their end of life when, for example, under the false impression that timely deactivation may allow for a more peaceful death.
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Affiliation(s)
- Irene Portig
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany
| | - Elif Karaaslan
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany
| | - Elena Hofacker
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany
| | - Christian Volberg
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany
| | - Carola Seifart
- Research Group Medical Ethics, Faculty of Medicine, Philipps University of Marburg, 35043 Marburg, Germany
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Stoevelaar R, Brinkman-Stoppelenburg A, van Bruchem-Visser RL, van Driel AG, Bhagwandien RE, Theuns DAMJ, Rietjens JAC, van der Heide A. Implantable cardioverter defibrillators at the end of life: future perspectives on clinical practice. Neth Heart J 2020; 28:565-570. [PMID: 32548800 PMCID: PMC7596123 DOI: 10.1007/s12471-020-01438-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The implantable cardioverter defibrillator (ICD) is effective in terminating life-threatening arrhythmias. However, in the last phase of life, ICD shocks may no longer be appropriate. Guidelines recommend timely discussion with the patient regarding deactivation of the shock function of the ICD. However, research shows that such conversations are scarce, and some patients experience avoidable and distressful shocks in the final days of life. Barriers such as physicians’ lack of time, difficulties in finding the right time to discuss ICD deactivation, patients’ reluctance to discuss the topic, and the fragmentation of care, which obscures responsibilities, prevent healthcare professionals from discussing this topic with the patient. In this point-of-view article, we argue that healthcare professionals who are involved in the care for ICD patients should be better educated on how to communicate with patients about ICD deactivation and the end of life. Optimal communication is needed to reduce the number of patients experiencing inappropriate and painful shocks in the terminal stage of their lives.
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Affiliation(s)
- R Stoevelaar
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - A Brinkman-Stoppelenburg
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R L van Bruchem-Visser
- Department of Internal Medicine, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A G van Driel
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - R E Bhagwandien
- Department of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - D A M J Theuns
- Department of Cardiology, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Abstract
In this paper, I consider the role of conscience in medical practice. If the conscientious practice of individual practitioners cannot be defended or is incoherent or unreasonable on its own merits, then there is little reason to support conscience protection and to argue about its place in the current medical landscape. If this is the case, conscience protection should be abandoned. To the contrary, I argue that conscience protection should not be abandoned. My argument takes the form of an analysis of an essential feature of the conscience dissenter's argument, the role of disagreement within "the medical profession." Conscience dissenters make certain assumptions within their arguments about the profession, disagreements within the professions, and how such disagreement should be adjudicated. If it is the case that these assumptions are accurate reflections of the current medical landscape, then the advocate of conscience protection has one less leg to stand on. I aim to show that this is not the case and that the assumptions of the conscience dissenter are not only mistaken but are mistakes of significant magnitude, so significant as to raise serious questions about the merit of their position. If the argument in this paper is sound, then, at the very least, the conversation over conscience protection in medicine, in particular, and health care, in general, must continue.
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Pilkington BC. Treating or Killing? The Divergent Moral Implications of Cardiac Device Deactivation. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 45:28-41. [DOI: 10.1093/jmp/jhz031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
In this article, I argue that there is a moral difference between deactivating an implantable cardioverter defibrillator (ICD) and turning off a cardiac pacemaker (CP). It is, at least in most cases, morally permissible to deactivate an ICD. It is not, at least in most cases, morally permissible to turn off a pacemaker in a fully or significantly pacemaker-dependent patient. After describing the relevant medical technologies—pacemakers and ICDs—I continue with contrasting perspectives on the issue of deactivation from practitioners involved with these devices: physicians, nurses, and allied professionals. Next, I offer a few possible analyses of the situation, relying on recent work in medical ethics. Considerations of intention, responsibility, and replacement support my distinguishing between ICDs and CPs. I conclude by recommending a change in policy of one of the leading cardiac societies.
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm 2019; 16:e128-e226. [DOI: 10.1016/j.hrthm.2018.10.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/13/2022]
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7
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2019; 140:e382-e482. [DOI: 10.1161/cir.0000000000000628] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Kenneth A. Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- ACC/AHA Representative
| | - Michael R. Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
| | | | | | - José A. Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N. Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
- Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
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DeFilippis EM, Nakagawa S, Maurer MS, Topkara VK. Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. J Am Geriatr Soc 2019; 67:2410-2419. [DOI: 10.1111/jgs.16105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Ersilia M. DeFilippis
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Shunichi Nakagawa
- Adult Palliative Care, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
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9
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. J Am Coll Cardiol 2019; 74:e51-e156. [DOI: 10.1016/j.jacc.2018.10.044] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Dutzmann J, Israel CW. [Device therapy in cardiological palliative care situations]. Herzschrittmacherther Elektrophysiol 2019; 30:204-211. [PMID: 31049654 DOI: 10.1007/s00399-019-0623-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There is considerable uncertainty about the management of patients with cardiac implantable electronic devices (CIEDs) threatened by immediate or medium-term death due to heart failure or other disease, for patients and their relatives as well as for physicians and medical staff. Patients can be afraid that they cannot die as long as pacing persists; medical staff may forget to deactivate shock therapies in an agonal phase or may not know how to do this without a programmer. For optimal handling of CIEDs in a palliative care situation, patients have to be informed that pacemakers or cardiac resynchronization therapy have no life-prolonging effect in this situation but only limit suffering, particularly due to dyspnea. Palliative care physicians must be informed that ICDs can be temporarily deactivated by magnet application, requiring neither a device specialist nor a programmer. Medical staff has to be trained in empathic discussions about CIED deactivation. An optimal setting for this talk may occur if the patient asks about the course and prognosis of his disease or an advance directive, which includes statements about resuscitation. Palliative care physicians have to understand the different functions of a CIED (antibradycardia pacing, resynchronization, antitachycardia pacing, shock therapy) and the deactivation of each of these components to ensure an appropriate decision; otherwise, CIED management at the end of a patient's life may cause suffering and a sense of guilt in relatives and medical staff.
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Affiliation(s)
- Jochen Dutzmann
- Mitteldeutsches Herzzentrum, Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - Carsten W Israel
- Klinik für Innere Medizin - Kardiologie, Diabetologie und Nephrologie, Evangelisches Klinikum Bethel, Bielefeld, Deutschland
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11
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LeQuang J, Magnusson P, Pergolizzi J. Implantable cardioverter-defibrillator therapy at end of life: A commentary. HEART AND MIND 2019. [DOI: 10.4103/hm.hm_15_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Khera R, Pandey A, Link MS, Sulistio MS. Managing Implantable Cardioverter-Defibrillators at End-of-Life: Practical Challenges and Care Considerations. Am J Med Sci 2018; 357:143-150. [PMID: 30665495 DOI: 10.1016/j.amjms.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 01/11/2023]
Abstract
Implantable cardioverter-defibrillators (ICDs) monitor for and terminate malignant arrhythmias. Given their potential as a life-saving therapy, an increasing number of people receive an ICD every year, and a growing number are currently living with ICDs. However, cardiopulmonary arrest serves as the final common pathway of natural death, and the appropriate management of an ICD near the end-of-life is crucial to ensure that a patient's death is not marked by further suffering due to ICD shocks. The tenets of palliative care at the end-of-life include addressing any medical intervention that may preclude dying with dignity; thus, management of ICDs during this phase is necessary. Internists are at the forefront of discussions about end-of-life care, and are likely to find discussions about ICD care at the end-of-life particularly challenging. The present review addresses issues pertaining to ICDs near the end of a patient's life and their potential impact on dying patients and their families. A multidisciplinary, patient-centered approach can ensure that patients receive the maximum benefit from ICDs, without any unintended pain or suffering.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark S Link
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Melanie S Sulistio
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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13
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2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm 2018; 15:e73-e189. [DOI: 10.1016/j.hrthm.2017.10.036] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 02/07/2023]
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14
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 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. Circulation 2018; 138:e272-e391. [PMID: 29084731 DOI: 10.1161/cir.0000000000000549] [Citation(s) in RCA: 264] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - William G Stevenson
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael J Ackerman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - William J Bryant
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - David J Callans
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne B Curtis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Barbara J Deal
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Timm Dickfeld
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael E Field
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Gregg C Fonarow
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne M Gillis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Christopher B Granger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Stephen C Hammill
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Mark A Hlatky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - José A Joglar
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - G Neal Kay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Daniel D Matlock
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Robert J Myerburg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Richard L Page
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 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. J Am Coll Cardiol 2018; 72:e91-e220. [PMID: 29097296 DOI: 10.1016/j.jacc.2017.10.054] [Citation(s) in RCA: 707] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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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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How Medicine Has Changed the End of Life for Patients With Cardiovascular Disease. J Am Coll Cardiol 2017; 70:1276-1289. [DOI: 10.1016/j.jacc.2017.07.735] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 12/20/2022]
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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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19
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End of life decisions in heart failure: to turn off the intracardiac device or not? Curr Opin Cardiol 2017; 32:224-228. [PMID: 28079553 DOI: 10.1097/hco.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Heart failure is a significant public health concern around the world. Implantable cardioverter defibrillators with or without cardiac resynchronization therapy (CRT-D) have proven survival benefit. As patients progress to end-stage disease, management shifts to palliative care, and cardiologists are often confronted with how to best manage these devices. RECENT FINDINGS Studies suggest that up to one-third of patients with an implantable cardioverter defibrillator receive painful shocks in the last 24 h of life. Disabling pacing or resynchronization devices may further weaken the heart function and expedite death, particularly if the patient has no underlying ventricular rhythm. Is it ethical or legal to discontinue functions of the implantable device? The discussion and the decision to be made are whether to continue both pacing and tachyarrhythmia therapies, disable tachyarrhythmia therapies while maintaining pacing, or discontinue both. SUMMARY The decision to disable all or parts of the device function is ultimately up to the patient. To avoid painful shocks near the end of life, it is recommended that tachyarrhythmia therapies be turned off when the patient is being treated palliatively. After informed discussion, withdrawing the resynchronization or pacing device option is also acceptable if requested by the patient regardless of the potential outcomes.
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20
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The ethics of unilateral implantable cardioverter defibrillators and cardiac resynchronization therapy with defibrillator deactivation: patient perspectives. Europace 2016; 19:1343-1348. [DOI: 10.1093/europace/euw227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/28/2016] [Indexed: 11/14/2022] Open
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21
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Alhammad NJ, O'Donnell M, O'Donnell D, Mariani JA, Gould PA, McGavigan AD. Cardiac Implantable Electronic Devices and End-of-Life Care: An Australian Perspective. Heart Lung Circ 2016; 25:814-9. [PMID: 27320854 DOI: 10.1016/j.hlc.2016.05.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/05/2016] [Indexed: 11/15/2022]
Abstract
Cardiac implantable electronic devices (pacemakers and defibrillators) are increasingly common in modern cardiology practice, and health professionals from a variety of specialties will encounter patients with such devices on a frequent basis. This article will focus on the subset of patients who may request, or be appropriate for, device deactivation and discuss the issues surrounding end-of-life decisions, along with the ethical and legal implications of device deactivation.
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Affiliation(s)
- Nasser J Alhammad
- Department of Cardiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - Mark O'Donnell
- Department of Cardiology, Austin Hospital, Melbourne, Vic., Australia
| | - David O'Donnell
- Department of Cardiology, Austin Hospital, Melbourne, Vic., Australia
| | - Justin A Mariani
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic., Australia
| | - Paul A Gould
- University of Queensland and Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld., Australia
| | - Andrew D McGavigan
- Department of Cardiology, Flinders Medical Centre, Adelaide, SA, Australia; Faculty of Medicine, Flinders University of South Australia, Adelaide, SA, Australia.
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22
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Kramer DB, Reynolds MR, Normand SL, Parzynski CS, Spertus JA, Mor V, Mitchell SL. Hospice Use Following Implantable Cardioverter-Defibrillator Implantation in Older Patients: Results From the National Cardiovascular Data Registry. Circulation 2016; 133:2030-7. [PMID: 27016104 PMCID: PMC4872640 DOI: 10.1161/circulationaha.115.020677] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/23/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older recipients of implantable cardioverter-defibrillators (ICDs) are at increased risk for short-term mortality in comparison with younger patients. Although hospice use is common among decedents aged >65, its use among older ICD recipients is unknown. METHODS AND RESULTS Medicare patients aged >65 matched to data in the National Cardiovascular Data Registry - ICD Registry from January 1, 2006 to March 31, 2010 were eligible for analysis (N=194 969). The proportion of ICD recipients enrolled in hospice, cumulative incidence of hospice admission, and factors associated with time to hospice enrollment were evaluated. Five years after device implantation, 50.9% of patients were either deceased or in hospice. Among decedents, 36.8% received hospice services. The cumulative incidence of hospice enrollment, accounting for the competing risk of death, was 4.7% (95% confidence interval [CI], 4.6%-4.8%) within 1 year and 21.3% (95% CI, 20.7%-21.8%) at 5 years. Factors most strongly associated with shorter time to hospice enrollment were older age (adjusted hazard ratio, 1.77; 95% CI, 1.73-1.81), class IV heart failure (versus class I; adjusted hazard ratio, 1.79; 95% CI, 1.66-1.94); ejection fraction <20 (adjusted hazard ratio, 1.57; 95% CI, 1.48-1.67), and greater hospice use among decedents in the patients' health referral region. CONCLUSIONS More than one-third of older patients dying with ICDs receive hospice care. Five years after implantation, half of older ICD recipients are either dead or in hospice. Hospice providers should be prepared for ICD patients, whose clinical trajectories and broader palliative care needs require greater focus.
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Affiliation(s)
- Daniel B Kramer
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.).
| | - Matthew R Reynolds
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Sharon-Lise Normand
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Craig S Parzynski
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - John A Spertus
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Vincent Mor
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
| | - Susan L Mitchell
- From Hebrew SeniorLife Institute for Aging Research, Boston MA (D.B.K., S.L.M.); Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston MA (D.B.K.); Harvard Medical School, Boston MA (D.B.K., S.L.M.); Harvard Clinical Research Institute, Boston MA (M.R.R.); Lahey Hospital & Medical Center, Burlington, MA (M.R.R.); Department of Health Care Policy, Harvard Medical School, Boston, MA (S.-L.N.); Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA (S.-L.N.); Center for Outcomes Research and Evaluation, Yale New Haven Hospital, Yale University, New Haven, CT (C.S.P.); Mid America Heart Institute, Kansas City, MO (J.A.S.); and Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (V.M.)
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23
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Jurgens CY, Goodlin S, Dolansky M, Ahmed A, Fonarow GC, Boxer R, Arena R, Blank L, Buck HG, Cranmer K, Fleg JL, Lampert RJ, Lennie TA, Lindenfeld J, Piña IL, Semla TP, Trebbien P, Rich MW. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America. J Card Fail 2016; 21:263-99. [PMID: 25863664 DOI: 10.1016/j.cardfail.2015.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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24
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Gura MT. Considerations in Patients With Cardiac Implantable Electronic Devices at End of Life. AACN Adv Crit Care 2015. [DOI: 10.4037/nci.0000000000000111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Since the introduction of implantable cardiac pacemakers in 1958 and implantable cardioverter-defibrillators in 1980, these devices have been proven to save and prolong lives. Pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy are deemed life-sustaining therapies. Despite these life-saving technologies, all patients ultimately will reach the end of their lives from either their heart disease or development of a terminal illness. Clinicians may be faced with patient and family requests to withdraw these life-sustaining therapies. The purpose of this article is to educate clinicians about the legal and ethical principles that underlie withdrawal of life-sustaining therapies such as device deactivation and to highlight the importance of proactive communication with patients and families in these situations.
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Affiliation(s)
- Melanie T. Gura
- Melanie T. Gura is Director, Pacemaker & Arrhythmia Services, Northeast Ohio Cardiovascular Specialists, Towbridge Dr, Hudson, OH 44236
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25
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Macková M. Deactivation of pacemakers and ICDs at the end of life. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2015. [DOI: 10.15452/cejnm.2015.06.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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26
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Pasalic D, Gazelka HM, Topazian RJ, Buchhalter LC, Ottenberg AL, Webster TL, Swetz KM, Mueller PS. Palliative Care Consultation and Associated End-of-Life Care After Pacemaker or Implantable Cardioverter-Defibrillator Deactivation. Am J Hosp Palliat Care 2015; 33:966-971. [PMID: 26169518 DOI: 10.1177/1049909115595017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The presence of cardiac pacemakers and defibrillators complicates making end-of-life (EOL) medical decisions. Palliative care/medicine consultation (PCMC) may benefit patients and primary providers, but data are lacking. We retrospectively reviewed 150 charts of patients who underwent device deactivation at our tertiary care center (between November 1, 2008, and September 1, 2012), assessing for PCMC and outcomes. Overall, 42% of patients received a PCMC, and 68% of those PCMCs specifically addressed device deactivation. Median survival following deactivation was 2 days, with 42% of deaths occurring within 1 day of deactivation. There was no difference in survival between the groups. The EOL care for patients with implanted cardiac devices is complex, but PCMC may assist with symptom management and clarification of goals of care for such patients.
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Affiliation(s)
- Dario Pasalic
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Rachel J Topazian
- Mayo Clinic Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | | | - Abigale L Ottenberg
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN, USA.,SSH Health, Mission, Legal and Government Affairs, St Louis, MO, USA
| | - Tracy L Webster
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Keith M Swetz
- Mayo Clinic Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Birmingham VA Medical Center, Birmingham, AL, USA
| | - Paul S Mueller
- Mayo Clinic Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN, USA
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27
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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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28
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Kramer DB, Matlock DD, Buxton AE, Goldstein NE, Goodwin C, Green AR, Kirkpatrick JN, Knoepke C, Lampert R, Mueller PS, Reynolds MR, Spertus JA, Stevenson LW, Mitchell SL. Implantable Cardioverter-Defibrillator Use in Older Adults: Proceedings of a Hartford Change AGEnts Symposium. Circ Cardiovasc Qual Outcomes 2015; 8:437-46. [PMID: 26038525 DOI: 10.1161/circoutcomes.114.001660] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel B Kramer
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.).
| | - Daniel D Matlock
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Alfred E Buxton
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Nathan E Goldstein
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Carol Goodwin
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Ariel R Green
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - James N Kirkpatrick
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Christopher Knoepke
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Rachel Lampert
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Paul S Mueller
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Matthew R Reynolds
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - John A Spertus
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Lynne W Stevenson
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Susan L Mitchell
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
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Pfeiffer D, Hagendorff A, Kühne C, Reinhardt S, Klein N. [Implantable cardioverter-defibrillator at the end of life]. Herzschrittmacherther Elektrophysiol 2015; 26:134-140. [PMID: 26001358 DOI: 10.1007/s00399-015-0366-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/24/2015] [Indexed: 06/04/2023]
Abstract
Brady- and tachyarrhythmias at the end of life are common observations. Implantable cardioverter-defibrillators answer with antibrady and antitachycardia pacing, which will not be associated with any complaints of the dying patient. In contrast, defibrillation and cardioversion shocks are extremely painful. Therefore shocks should be inactivated at the end of life. Family doctors, internists, emergency physicians and paramedics are unable to inactivate shocks. Deactivation of shocks at the end of life is not comparable to euthanasia or assisted suicide, but allow the patient to die at the end of an uncurable endstage disease. Deactivation of shocks should be discussed with the patient before initial implantation of the devices. The precise moment of the inactivation at the end of life should be discussed with patients and relatives. There is no common recommendation for the time schedule of this decision; therefore it should be based on the individual situation of the patient. Emergency health care physicians need magnets and sufficient information to inactivate defibrillators. The wishes of the patient have priority in the decision process and should be written in the patient's advance directive, which must be available in the final situation. However the physician must not necessarily follow every wish of the patient. As long as the laws in the European Union are not uniform, German recommendations are needed.
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Affiliation(s)
- D Pfeiffer
- Abt. Kardiologie & Angiologie, Dept. Innere Medizin, Neurologie und Dermatologie, Universität Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland,
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LAMPERT RACHEL. “Unilateral ICD Deactivation”: No Ethical Leg to Stand On. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:914-6. [DOI: 10.1111/pace.12645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/12/2015] [Indexed: 11/30/2022]
Affiliation(s)
- RACHEL LAMPERT
- Yale University School of Medicine; New Haven Connecticut
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Hill L, McIlfatrick S, Taylor BJ, Dixon L, Cole BR, Moser DK, Fitzsimons D. Implantable cardioverter defibrillator (ICD) deactivation discussions: Reality versus recommendations. Eur J Cardiovasc Nurs 2015; 15:20-9. [DOI: 10.1177/1474515115584248] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/02/2015] [Indexed: 01/06/2023]
Affiliation(s)
- Loreena Hill
- Ulster University, Newtownabbey, UK
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
| | - Sonja McIlfatrick
- Ulster University, Newtownabbey, UK
- All Ireland Institute of Hospice and Palliative Care, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin, Ireland
| | | | - Lana Dixon
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
| | - Ben R Cole
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
| | - Debra K Moser
- Ulster University, Newtownabbey, UK
- University of Kentucky, College of Nursing, Lexington, USA
| | - Donna Fitzsimons
- Ulster University, Newtownabbey, UK
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
- All Ireland Institute of Hospice and Palliative Care, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin, Ireland
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Jurgens CY, Goodlin S, Dolansky M, Ahmed A, Fonarow GC, Boxer R, Arena R, Blank L, Buck HG, Cranmer K, Fleg JL, Lampert RJ, Lennie TA, Lindenfeld J, Piña IL, Semla TP, Trebbien P, Rich MW. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America. Circ Heart Fail 2015; 8:655-87. [PMID: 25855686 DOI: 10.1161/hhf.0000000000000005] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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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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Sterben mit/trotz Schrittmachers. Med Klin Intensivmed Notfmed 2014; 109:19-26. [DOI: 10.1007/s00063-013-0282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 11/20/2013] [Indexed: 11/25/2022]
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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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Thylén I, Moser DK, Chung ML, Miller J, Fluur C, Strömberg A. Are ICD recipients able to foresee if they want to withdraw therapy or deactivate defibrillator shocks? INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2013; 1:22-31. [PMID: 29450154 PMCID: PMC5801008 DOI: 10.1016/j.ijchv.2013.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 11/01/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Expert consensus statements on management of implantable cardioverter defibrillators (ICDs) emphasize the importance of having discussions about deactivation before and after implantation. These statements were developed with limited patient input. The purpose of this study was to identify the factors associated with patients' experiences of end-of-life discussions, attitudes towards such discussions, and attitudes towards withdrawal of therapy (i.e., generator replacement and deactivation) at end-of-life, in a large national cohort of ICD-recipients. METHODS We enrolled 3067 ICD-patients, administrating the End-of-Life-ICD-Questionnaire. RESULTS Most (86%) had not discussed ICD-deactivation with their physician. Most (69%) thought discussions were best at end-of-life, but 40% stated that they never wanted the physician to initiate a discussion. Those unwilling to discuss deactivation were younger, had experienced battery replacement, had a longer time since implantation, and had better quality-of-life. Those with psychological morbidity were more likely to desire a discussion about deactivation. Many patients (39%) were unable to foresee what to decide about deactivation in an anticipated terminal condition. Women, those without depression, and those with worse ICD-related experiences were more indecisive about withdrawal of therapy. Irrespective of shock experiences, those who could take a stand regarding deactivation chose to keep shock therapies active in many cases (39%). CONCLUSIONS Despite consensus statements recommending discussions about ICD-deactivation at the end-of-life, such discussion usually do not occur. There is substantial ambivalence and indecisiveness on the part of most ICD-patients in this nationwide survey about having these discussions and about expressing desires about deactivation in an anticipated end-of-life situation.
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Affiliation(s)
- Ingela Thylén
- Division of Nursing Sciences, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Cardiology, County Council of Östergötland, Linköping, Sweden
- Department of Cardiology, County Council of Östergötland, Linköping, Sweden
| | - Debra K. Moser
- College of Nursing, University of Kentucky, Lexington, USA
| | | | | | - Christina Fluur
- Department of Cardiology, County Council of Östergötland, Linköping, Sweden
| | - Anna Strömberg
- Division of Nursing Sciences, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Cardiology, County Council of Östergötland, Linköping, Sweden
- Department of Cardiology, County Council of Östergötland, Linköping, Sweden
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38
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Lampert R. Implantable cardioverter-defibrillator shocks in dying patients: disturbing data from beyond the grave. Circulation 2013; 129:414-6. [PMID: 24243856 DOI: 10.1161/circulationaha.113.006939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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Pettit SJ, Jackson CE, Gardner RS. Deactivation of implantable cardioverter-defibrillators at end of life. Future Cardiol 2013; 9:885-96. [PMID: 24180544 DOI: 10.2217/fca.13.81] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
It is inevitable that all patients with implantable cardioverter-defibrillators (ICDs) will die during extended follow-up. End-of-life care planning may become appropriate as a patient's condition deteriorates. There is concern about multiple futile shocks in the final hours of life, although the incidence of this problem has been estimated at only 8-16%. Despite broad consensus that ICD deactivation should be discussed as part of end-of-life care planning, the effect of ICD deactivation, in particular whether life expectancy is altered, is uncertain. Many clinicians are reluctant to discuss ICD deactivation. Many patients have misconceptions regarding ICD function and value longevity above quality of life. As such, ICD deactivation is often discussed late or not at all. The management of ICDs in patients approaching death is likely to become a major problem in the coming years. This article will discuss directions in which clinical practice might develop and areas for future research.
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Affiliation(s)
- Stephen J Pettit
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK.
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41
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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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Swetz KM, Cook KE, Ottenberg AL, Chang N, Mueller PS. Clinicians' attitudes regarding withdrawal of left ventricular assist devices in patients approaching the end of life. Eur J Heart Fail 2013; 15:1262-6. [PMID: 23744792 DOI: 10.1093/eurjhf/hft094] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Left ventricular assist devices (LVADs) are implanted to support the circulation of patients with advanced heart failure. Patients approaching death, or their surrogates, may request withdrawal of LVAD support. We sought to study the attitudes and practices of heart failure clinicians regarding withdrawal of LVAD support in patients approaching death. METHODS AND RESULTS Using internet-based and secure methods, we surveyed members of the European Society of Cardiology-Heart Failure Association (ESC-HFA), the International Society for Heart and Lung Transplantation (ISHLT), and the Heart Failure Society of America (HFSA) to assess their attitudes and practices regarding LVAD withdrawal for patients approaching death. The results indicated that clinicians have varied attitudes and practices regarding withdrawing LVAD support in these patients. Furthermore, ESC-HFA clinicians (primarily European) and ISHLT and HFSA clinicians (primarily North American) differed in their attitudes and practices regarding withdrawal of LVAD support, particularly its ethical and legal permissibility. For example, more European clinicians than North American clinicians regarded withdrawing LVAD support as a form of euthanasia. CONCLUSION Opinions and level of comfort with LVAD withdrawal vary among clinicians. Clinicians should be aware of suggested approaches or guidelines for managing requests for withdrawal of LVAD therapy.
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Affiliation(s)
- Keith M Swetz
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
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.
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Affiliation(s)
- Daniel D Matlock
- University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Ethical and legal perspective of implantable cardioverter defibrillator deactivation or implantable cardioverter defibrillator generator replacement in the elderly. Curr Opin Cardiol 2013; 28:43-9. [DOI: 10.1097/hco.0b013e32835b0b3b] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Huddle TS, Amos Bailey F. Pacemaker deactivation: withdrawal of support or active ending of life? THEORETICAL MEDICINE AND BIOETHICS 2012; 33:421-433. [PMID: 22351107 DOI: 10.1007/s11017-012-9213-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In spite of ethical analyses assimilating the palliative deactivation of pacemakers to commonly accepted withdrawings of life-sustaining therapy, many clinicians remain ethically uncomfortable with pacemaker deactivation at the end of life. Various reasons have been posited for this discomfort. Some cardiologists have suggested that reluctance to deactivate pacemakers may stem from a sense that the pacemaker has become part of the patient's "self." The authors suggest that Daniel Sulmasy is correct to contend that any such identification of the pacemaker is misguided. The authors argue that clinicians uncomfortable with pacemaker deactivation are nevertheless correct to see it as incompatible with the traditional medical ethics of withdrawal of support. Traditional medical ethics is presently taken by many to sanction pacemaker deactivation when such deactivation honors the patient's right to refuse treatment. The authors suggest that the right to refuse treatment applies to treatments involving ongoing physician agency. This right cannot underwrite patient demands that physicians reverse the effects of treatments previously administered, in which ongoing physician agency is no longer implicated. The permanently indwelling pacemaker is best seen as such a treatment. As such, its deactivation in the pacemaker-dependent patient is best seen not as withdrawal of support but as active ending of life. That being the case, clinicians adhering to the usual ethical analysis of withdrawal of support are correct to be uncomfortable with pacemaker deactivation at the end of life.
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Affiliation(s)
- Thomas S Huddle
- FOT 744, Division of General Internal Medicine, University of Alabama at Birmingham (UAB) School of Medicine, Birmingham VA Medical Center, Birmingham, AL 35294, USA.
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Abstract
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.
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Affiliation(s)
- Daniel B Kramer
- Hebrew SeniorLife Institute for Aging Research, Boston, MA, USA.
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Malpas PJ, Cooper L. The Ethics of Deactivating a Pacemaker in a Pacing-Dependent Patient. Am J Hosp Palliat Care 2012; 29:566-9. [DOI: 10.1177/1049909111432624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Phillipa J. Malpas
- Department of Psychological Medicine, The University of Auckland, University of Auckland, New Zealand
| | - Lisa Cooper
- Physiology Department, Auckland City Hospital, Auckland, New Zealand
- New Zealand Certificate of Science (NZCS)
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Lampert R. Quality of Life and End-Of-Life Issues for Older Patients with Implanted Cardiac Rhythm Devices. Clin Geriatr Med 2012; 28:693-702. [DOI: 10.1016/j.cger.2012.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Michael Mitar
- From the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Ana C. Alba
- From the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Jane MacIver
- From the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Heather Ross
- From the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
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Abstract
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.
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