Navigating end-of-life care for patients who require life-sustaining devices can be clinically and ethically challenging. Since annual mortality rates for recipients of pacemakers (PM) and implantable cardioverter-defibrillators (ICDs) are 5 percent to 20 percent, physicians caring for these patients are frequently confronted with the possibility of deactivating these devices. However, device deactivation during end-of-life care raises a number of ethical and legal issues. A team of Boston-based researchers surveyed 185 internal medicine physicians and subspecialists from a Massachusetts hospital to clarify clinicians' experience with the withdrawal of PM and ICD therapy in end-of-life patients and their views of the related ethical and legal issues.
Twenty-five percent to 49 percent of physicians viewed deactivation of PMs and ICDs as morally distinct from each other as well as from withdrawal of other life-sustaining therapies, such as mechanical ventilation, dialysis, and feeding tubes. Compared with deactivation of an ICD, physicians more often characterized deactivation of a PM in a pacemaker-dependent patient as physician-assisted suicide (19 percent vs. 10 percent) or euthanasia (9 percent vs. 1 percent). However, the researchers contend that although some may view PMs or ICDs as unique, there is no identifiable medical, legal, or ethical basis for this distinction.
The surveyed physicians had considerably more experience in the withdrawal or removal of mechanical ventilation, dialysis, and feeding tubes than with PMs or ICDs. Few physicians had personally deactivated either type of cardiac device in end-of-life patients (10 percent PMs, 11 percent ICDs). They were distinctly less comfortable discussing deactivation of PMs or ICDs compared with mechanical ventilation, dialysis, or feeding tubes. The physicians were queried about the withdrawal of therapy in several types of scenarios including brain death, coma with a very poor prognosis, and a stable outpatient with terminal cancer who requested withdrawal of treatment.
The researchers propose that efforts be undertaken to better educate health care providers about the methods, clinical implications, ethics, and legality of device deactivation. This study was supported by the Agency for Healthcare Research and Quality (HS18465).
See "Ethical and legal views of physicians regarding deactivations of cardiac implantable electrical devices: A quantitative assessment," by Daniel B. Kramer, M.D., Aaron S. Kesselheim, M.D., J.D., Dan W. Brock, Ph.D., and William H. Maisel, M.D., in Heart Rhythm 7, pp. 1537-1542, 2010.