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Clinicians' views regarding deactivation of cardiovascular implantable electronic devices in seriously ill patients
EDITORIAL COMMENTARY
Clinicians’ views regarding deactivation of cardiovascular implantable electronic devices in seriously ill patients Paul S. Mueller, MD From the Division of General Internal Medicine and the Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota. Prior surveys1– 6 have assessed clinicians’ experiences and perspectives regarding cardiovascular implantable electronic device (CIED) deactivation in seriously ill patients. These surveys generally have involved electrophysiologists and others who manage patients with these devices. In this issue of Heart Rhythm, Kramer et al7 add to this literature by reporting the results of a survey conducted at a single institution. What is unique about the survey is that of the 185 physicians who responded to the survey, 150 (81%) were generalists. The Kramer et al7 survey has several important findings. Most of the respondents (89%) reported being comfortable with discussing end-of-life care with patients. However, significantly fewer respondents reported being comfortable discussing with patients implantable cardioverter-defibrillator (ICD) deactivation (54%), pacemaker deactivation in nonpacemaker-dependent patients (50%), and pacemaker deactivation in pacemaker-dependent patients (41%) than discussing withdrawal of mechanical ventilation (89%), feeding tubes (85%), and hemodialysis (79%). These findings are not surprising. Most generalists are familiar with mechanical ventilation, feeding tubes, and hemodialysis. Furthermore, decades of bioethics analysis and research and highly publicized legal cases (e.g., Quinlan, Cruzan, and Schiavo) involving several life-prolonging treatments have established patients’ rights to refuse or request the withdrawal of these treatments and the ethical and legal permissibility of carrying out such requests.8 Most generalists are familiar with these principles. On the other hand, generalists do not have the same knowledge about and experience with CIEDs as electrophysiologists and others who manage patients with these devices.1 Furthermore, although CIEDs have been available for clinical use for many years, discussions regarding the ethical and legal permissibility of CIED deactivation are relatively new. Several reasons may account for this Dr. Mueller is a member of the Boston Scientific Patient Safety Advisory Board and is an Associate Editor of Journal Watch General Medicine. Address reprint requests and correspondence: Dr. Paul S. Mueller, Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail address: [email protected].
observation. Patients who undergo CIED implantations generally have good prognoses and may live for many years (unlike seriously ill patients who receive life-prolonging treatments such as mechanical ventilation as attempts to avert death). Hence, until recently, generalists may not have had opportunities to care for dying patients with CIEDs. Second, these devices (especially pacemakers) may not be viewed as barriers to peaceful deaths, and deactivation may not be considered. Finally, many seriously ill patients are cared for by specialists, who may not involve generalists in CIED deactivation discussions. Nevertheless, the strongest predictor of physician willingness to discuss ICD deactivation is a history of prior deactivation discussions.1 As the prevalence of patients with CIEDs grows,9 it is likely generalists will encounter patients who request (or whose surrogates request) CIED deactivation, and it is reasonable to expect that they will become comfortable discussing device deactivations with these patients. Significantly fewer Kramer et al7 survey respondents (34%) reported having participated in CIED deactivations than having participated in the withdrawal of mechanical ventilation (86%), feeding tubes (74%), and hemodialysis (61%). Even fewer respondents had personally deactivated CIEDs (about 10%). These results contrast with those with a prior survey5 of electrophysiologists and others who manage patients with CIEDs, in which a majority of respondents had cared for terminally ill patients who requested CIED deactivation and had personally deactivated these devices. Yet overall, the results of these 2 surveys are not surprising. For the same reasons related to comfort with discussing CIED deactivations, one would expect that fewer generalists have participated in and carried out CIED deactivations than electrophysiologists and others who manage patients with CIEDs. In addition, carrying out CIED deactivations requires technical expertise and programming equipment that generalists do not have. About 25% to 50% of the respondents to the Kramer et al7 survey viewed deactivating CIEDs as morally distinct from withdrawing other life-prolonging treatments. In addition, more respondents viewed pacemaker deactivation in pacemaker-dependent patients as euthanasia than ICD de-
1547-5271/$ -see front matter © 2010 Heart Rhythm Society. All rights reserved.
doi:10.1016/j.hrthm.2010.08.020
1544 activation (9% vs. 1%). These results are similar to those of prior surveys.5,6 The chief concern about deactivating a pacemaker in a pacemaker-dependent patient is that death may occur shortly after deactivation. This possibility, however, is not a morally relevant argument against deactivating a pacemaker when a patient perceives the device as burdensome and an impediment to a natural death. After all, clinicians commonly carry out requests to withdraw mechanical ventilation in seriously ill or dying patients who no longer want the treatment, and death usually occurs shortly after its withdrawal. Withdrawal of a life-sustaining treatment in a situation such as this is viewed as ethically and legally permissible; death that follows is attributed to the underlying disease, not to the act of withdrawing the treatment.8 In addition, many clinicians are comfortable with deactivating ICDs in patients who do not want antitachyarrhythmia therapies.1– 6 Yet, as one cannot predict the possibility of a patient being shocked by an ICD near the end of life,4 one cannot predict the possibility or timing of a patient experiencing a fatal arrhythmia after ICD deactivation. Nevertheless, although few clinicians view CIED deactivation as euthanasia, these clinicians’ views should be respected. One cannot compel a clinician to engage in a procedure he or she finds morally objectionable. Instead, care of the patient should be transferred to an accommodating colleague.8 Prior research indicates the less reversible a patient’s underlying disease, the more amenable clinicians are to withdrawing life-prolonging treatments,10 including CIED therapies.1,2 Respondents to the Kramer et al7 survey were comfortable withdrawing mechanical ventilation, feeding tubes, and hemodialysis from critically ill patients with poor prognosis and stable outpatients with terminal cancer. They were also comfortable with deactivating CIEDs in patients with brain death, comatose patients with poor prognosis, and patients with terminal cancer, except for deactivating pacemakers in pacemaker-dependent patients with terminal cancer. Clinicians should be aware, however, that a patient, regardless of his or her clinical status, has the right to refuse or request the withdrawal of any treatment and that no treatment, including a CIED therapy, has unique moral status, i.e., must be continued once started.8 Less than 2% of respondents to the Kramer et al7 survey reported requesting ethics or legal consultation in response to CIED deactivation requests. This result is consistent with that of a prior survey.5 This finding is concerning given the numbers of respondents who expressed moral qualms about, and had legal knowledge deficiencies regarding, CIED deactivations. When faced with ethical dilemmas or legal questions, clinicians should seek guidance. Most health care institutions have readily accessible ethics and legal consultation. About 1 in 5 respondents to the Kramer et al7 survey did not believe the informed consent process prior to CIED implantation adequately addressed the possibility of device deactivation. Indeed, evidence suggests that few patients with CIEDs are aware that device deactivation is an op-
Heart Rhythm, Vol 7, No 11, November 2010 tion.4,8 However, most clinicians believe informed consent for ICD implantation should include information about device deactivation.1 In addition to informing patients of this option, clinicians should also inform patients of any moral qualms they have regarding device deactivation.8 About half of the respondents to the Kramer et al7 survey thought expert guidance related to CIED deactivation in dying patients would be helpful. Fortunately, the Heart Rhythm Society recently released an Expert Consensus Statement8 on this topic. Clinicians who implant and manage patients with CIEDs should be familiar with this important document. Notably, the Heart Rhythm Society statement recommends that all patients considered for or who have CIEDs be encouraged to engage in advance care planning—a process in which a patient identifies a surrogate and articulates and documents his or her health care values, goals, and preferences (e.g., in an advance directive). Advance care planning may prevent ethical dilemmas, such as what to do when a patient’s surrogate requests device deactivation, and may prevent unwanted treatments, such ICD shocks in a dying patient. Unfortunately, few patients with CIEDs engage in device-specific advance care planning. Nevertheless, clinicians are likely to be more comfortable carrying out CIED deactivation requests if patients’ end-of-life values, goals, and preferences are clearly and specifically (i.e., regarding the device) documented.8 Future research should focus on enhancing advance care planning in patients who are being considered for or who have CIEDs.
References 1. Kelley AS, Reid MC, Miller DH, Fins JJ, Lachs MS. Implantable cardioverterdefibrillator deactivation at the end of life: a physician survey. Am Heart J 2009;157:702–708. 2. Marinskis G, van Erven L, for the EHRA Scientific Initiatives Committee. Deactivation of implanted cardioverter-defibrillators at the end of life: results of the EHRA survey. Europace 2010;12:1176 –1177. 3. Sherazi S, Daubert JP, Block RC, et al. Physicians’ preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator. Mayo Clin Proc 2008;83:1139 –1141. 4. Goldstein N, Bradley E, Zeidman J, Mehta D, Morrison RS. Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians. J Am Coll Cardiol 2009;54:371–374. 5. Mueller PS, Jenkins SM, Bramstedt KA, Hayes DL. Deactivating implanted cardiac devices in terminally ill patients: practices and attitudes. Pacing Clin Electrophysiol 2008;31:560 –568. 6. Kapa S, Mueller PS, Hayes DL, Asirvatham SJ. Withdrawal of ICD and pacemaker therapy in terminally ill patients: a survey of healthcare and legal professionals. Heart Rhythm 2009;6:S261. 7. Kramer DB, Kesselheim AS, Brock DW, Maisel WH. Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment. Heart Rhythm 2010;1537–1542. 8. Lampert R, Hayes DL, Annas GJ, et al. American College of Cardiology; American Geriatrics Society; American Academy of Hospice and Palliative Medicine; American Heart Association; European Heart Rhythm Association; Hospice and Palliative Nurses Association. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing the end of life or requesting withdrawal of therapy. Heart Rhythm 2010;7:1008 –1026. 9. Mond HG, Irwin M, Ector H, Proclemer A. The world survey of cardiac pacing and cardioverter-defibrillators: calendar year 2005 an International Cardiac Pacing and Electrophysiology (ICPES) project. Pacing Clin Electrophysiol 2008; 31:1202–1212. 10. Farber NJ, Simpson P, Salam T, Collier VU, Weiner J, Boyer EG. Physicians’ decisions to withhold and withdraw life-sustaining treatment. Arch Intern Med 2006;166:560 –564.
Clinicians’ views regarding deactivation of cardiovascular implantable electronic devices in seriously ill patients Paul S. Mueller, MD From the Division of General Internal Medicine and the Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota. Prior surveys1– 6 have assessed clinicians’ experiences and perspectives regarding cardiovascular implantable electronic device (CIED) deactivation in seriously ill patients. These surveys generally have involved electrophysiologists and others who manage patients with these devices. In this issue of Heart Rhythm, Kramer et al7 add to this literature by reporting the results of a survey conducted at a single institution. What is unique about the survey is that of the 185 physicians who responded to the survey, 150 (81%) were generalists. The Kramer et al7 survey has several important findings. Most of the respondents (89%) reported being comfortable with discussing end-of-life care with patients. However, significantly fewer respondents reported being comfortable discussing with patients implantable cardioverter-defibrillator (ICD) deactivation (54%), pacemaker deactivation in nonpacemaker-dependent patients (50%), and pacemaker deactivation in pacemaker-dependent patients (41%) than discussing withdrawal of mechanical ventilation (89%), feeding tubes (85%), and hemodialysis (79%). These findings are not surprising. Most generalists are familiar with mechanical ventilation, feeding tubes, and hemodialysis. Furthermore, decades of bioethics analysis and research and highly publicized legal cases (e.g., Quinlan, Cruzan, and Schiavo) involving several life-prolonging treatments have established patients’ rights to refuse or request the withdrawal of these treatments and the ethical and legal permissibility of carrying out such requests.8 Most generalists are familiar with these principles. On the other hand, generalists do not have the same knowledge about and experience with CIEDs as electrophysiologists and others who manage patients with these devices.1 Furthermore, although CIEDs have been available for clinical use for many years, discussions regarding the ethical and legal permissibility of CIED deactivation are relatively new. Several reasons may account for this Dr. Mueller is a member of the Boston Scientific Patient Safety Advisory Board and is an Associate Editor of Journal Watch General Medicine. Address reprint requests and correspondence: Dr. Paul S. Mueller, Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail address: [email protected].
observation. Patients who undergo CIED implantations generally have good prognoses and may live for many years (unlike seriously ill patients who receive life-prolonging treatments such as mechanical ventilation as attempts to avert death). Hence, until recently, generalists may not have had opportunities to care for dying patients with CIEDs. Second, these devices (especially pacemakers) may not be viewed as barriers to peaceful deaths, and deactivation may not be considered. Finally, many seriously ill patients are cared for by specialists, who may not involve generalists in CIED deactivation discussions. Nevertheless, the strongest predictor of physician willingness to discuss ICD deactivation is a history of prior deactivation discussions.1 As the prevalence of patients with CIEDs grows,9 it is likely generalists will encounter patients who request (or whose surrogates request) CIED deactivation, and it is reasonable to expect that they will become comfortable discussing device deactivations with these patients. Significantly fewer Kramer et al7 survey respondents (34%) reported having participated in CIED deactivations than having participated in the withdrawal of mechanical ventilation (86%), feeding tubes (74%), and hemodialysis (61%). Even fewer respondents had personally deactivated CIEDs (about 10%). These results contrast with those with a prior survey5 of electrophysiologists and others who manage patients with CIEDs, in which a majority of respondents had cared for terminally ill patients who requested CIED deactivation and had personally deactivated these devices. Yet overall, the results of these 2 surveys are not surprising. For the same reasons related to comfort with discussing CIED deactivations, one would expect that fewer generalists have participated in and carried out CIED deactivations than electrophysiologists and others who manage patients with CIEDs. In addition, carrying out CIED deactivations requires technical expertise and programming equipment that generalists do not have. About 25% to 50% of the respondents to the Kramer et al7 survey viewed deactivating CIEDs as morally distinct from withdrawing other life-prolonging treatments. In addition, more respondents viewed pacemaker deactivation in pacemaker-dependent patients as euthanasia than ICD de-
1547-5271/$ -see front matter © 2010 Heart Rhythm Society. All rights reserved.
doi:10.1016/j.hrthm.2010.08.020
1544 activation (9% vs. 1%). These results are similar to those of prior surveys.5,6 The chief concern about deactivating a pacemaker in a pacemaker-dependent patient is that death may occur shortly after deactivation. This possibility, however, is not a morally relevant argument against deactivating a pacemaker when a patient perceives the device as burdensome and an impediment to a natural death. After all, clinicians commonly carry out requests to withdraw mechanical ventilation in seriously ill or dying patients who no longer want the treatment, and death usually occurs shortly after its withdrawal. Withdrawal of a life-sustaining treatment in a situation such as this is viewed as ethically and legally permissible; death that follows is attributed to the underlying disease, not to the act of withdrawing the treatment.8 In addition, many clinicians are comfortable with deactivating ICDs in patients who do not want antitachyarrhythmia therapies.1– 6 Yet, as one cannot predict the possibility of a patient being shocked by an ICD near the end of life,4 one cannot predict the possibility or timing of a patient experiencing a fatal arrhythmia after ICD deactivation. Nevertheless, although few clinicians view CIED deactivation as euthanasia, these clinicians’ views should be respected. One cannot compel a clinician to engage in a procedure he or she finds morally objectionable. Instead, care of the patient should be transferred to an accommodating colleague.8 Prior research indicates the less reversible a patient’s underlying disease, the more amenable clinicians are to withdrawing life-prolonging treatments,10 including CIED therapies.1,2 Respondents to the Kramer et al7 survey were comfortable withdrawing mechanical ventilation, feeding tubes, and hemodialysis from critically ill patients with poor prognosis and stable outpatients with terminal cancer. They were also comfortable with deactivating CIEDs in patients with brain death, comatose patients with poor prognosis, and patients with terminal cancer, except for deactivating pacemakers in pacemaker-dependent patients with terminal cancer. Clinicians should be aware, however, that a patient, regardless of his or her clinical status, has the right to refuse or request the withdrawal of any treatment and that no treatment, including a CIED therapy, has unique moral status, i.e., must be continued once started.8 Less than 2% of respondents to the Kramer et al7 survey reported requesting ethics or legal consultation in response to CIED deactivation requests. This result is consistent with that of a prior survey.5 This finding is concerning given the numbers of respondents who expressed moral qualms about, and had legal knowledge deficiencies regarding, CIED deactivations. When faced with ethical dilemmas or legal questions, clinicians should seek guidance. Most health care institutions have readily accessible ethics and legal consultation. About 1 in 5 respondents to the Kramer et al7 survey did not believe the informed consent process prior to CIED implantation adequately addressed the possibility of device deactivation. Indeed, evidence suggests that few patients with CIEDs are aware that device deactivation is an op-
Heart Rhythm, Vol 7, No 11, November 2010 tion.4,8 However, most clinicians believe informed consent for ICD implantation should include information about device deactivation.1 In addition to informing patients of this option, clinicians should also inform patients of any moral qualms they have regarding device deactivation.8 About half of the respondents to the Kramer et al7 survey thought expert guidance related to CIED deactivation in dying patients would be helpful. Fortunately, the Heart Rhythm Society recently released an Expert Consensus Statement8 on this topic. Clinicians who implant and manage patients with CIEDs should be familiar with this important document. Notably, the Heart Rhythm Society statement recommends that all patients considered for or who have CIEDs be encouraged to engage in advance care planning—a process in which a patient identifies a surrogate and articulates and documents his or her health care values, goals, and preferences (e.g., in an advance directive). Advance care planning may prevent ethical dilemmas, such as what to do when a patient’s surrogate requests device deactivation, and may prevent unwanted treatments, such ICD shocks in a dying patient. Unfortunately, few patients with CIEDs engage in device-specific advance care planning. Nevertheless, clinicians are likely to be more comfortable carrying out CIED deactivation requests if patients’ end-of-life values, goals, and preferences are clearly and specifically (i.e., regarding the device) documented.8 Future research should focus on enhancing advance care planning in patients who are being considered for or who have CIEDs.
References 1. Kelley AS, Reid MC, Miller DH, Fins JJ, Lachs MS. Implantable cardioverterdefibrillator deactivation at the end of life: a physician survey. Am Heart J 2009;157:702–708. 2. Marinskis G, van Erven L, for the EHRA Scientific Initiatives Committee. Deactivation of implanted cardioverter-defibrillators at the end of life: results of the EHRA survey. Europace 2010;12:1176 –1177. 3. Sherazi S, Daubert JP, Block RC, et al. Physicians’ preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator. Mayo Clin Proc 2008;83:1139 –1141. 4. Goldstein N, Bradley E, Zeidman J, Mehta D, Morrison RS. Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians. J Am Coll Cardiol 2009;54:371–374. 5. Mueller PS, Jenkins SM, Bramstedt KA, Hayes DL. Deactivating implanted cardiac devices in terminally ill patients: practices and attitudes. Pacing Clin Electrophysiol 2008;31:560 –568. 6. Kapa S, Mueller PS, Hayes DL, Asirvatham SJ. Withdrawal of ICD and pacemaker therapy in terminally ill patients: a survey of healthcare and legal professionals. Heart Rhythm 2009;6:S261. 7. Kramer DB, Kesselheim AS, Brock DW, Maisel WH. Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment. Heart Rhythm 2010;1537–1542. 8. Lampert R, Hayes DL, Annas GJ, et al. American College of Cardiology; American Geriatrics Society; American Academy of Hospice and Palliative Medicine; American Heart Association; European Heart Rhythm Association; Hospice and Palliative Nurses Association. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing the end of life or requesting withdrawal of therapy. Heart Rhythm 2010;7:1008 –1026. 9. Mond HG, Irwin M, Ector H, Proclemer A. The world survey of cardiac pacing and cardioverter-defibrillators: calendar year 2005 an International Cardiac Pacing and Electrophysiology (ICPES) project. Pacing Clin Electrophysiol 2008; 31:1202–1212. 10. Farber NJ, Simpson P, Salam T, Collier VU, Weiner J, Boyer EG. Physicians’ decisions to withhold and withdraw life-sustaining treatment. Arch Intern Med 2006;166:560 –564.