Cardiac Implantable Electronic Devices (CIEDs – a cover-all term for permanent pacemakers and implantable defibrillators) are becoming increasingly common in the population as a whole and therefore are becoming increasingly encountered by health professionals delivering End-of-Life (EoL) care. This can result in ethical dilemmas around switching off or modifying the therapies delivered by these devices.
There’s a very interesting article with 2 accompanying editorials in this month’s JAMA Internal Medicine (the journal formerly known as Archives of Internal Medicine) looking at the potentially thorny issues around de-activating CIEDs. All are free, open access.
The article, by Buchhalter et al, is a retrospective chart review covering a 4 year period from 2008-2012 and looking at all patients who had a CIED deactivated at the Mayo Clinic in Minnesota.
- 159 requests for deactivation
- 9 requests not carried out
- 2 of the non deactivations were physician refusals (I found this particularly interesting). In both cases the patient had a PPM and requested that it be turned off, which is a slightly different issue compared with turning off an ICD. In one case the physician requested an ethics consult but the patient died before it could be arranged. In the second case the physician refused to deactivate the device but referred the patient to another physician. Again the patient died before the consult took place.
- Of the remaining 150 patients who underwent device deactivation, 99% had a terminal prognosis (the one patient who didn’t was getting inappropriate shocks from an ICD)
- Most of the patients had an ICD and only had tachycardia therapies stopped. Some of them also had bradycardia therapies deactivated. A small number of the patients were pacemaker dependant and had bradycardia therapies deactivated.
- Half of the requests were from patients and half from surrogate decision makers (SDMs)
- 57% of the patients had an advanced directive, but only one of them mentioned the CIED!
- 27% of patients who had tachycardia therapies deactivated died within a day of deactivation, 71% within a week, 87% within a month.
- Of those who also had bradycardia therapies switched off, 53% died within a day, 88% within a week.
The authors mention in the discussion that most of the requests were for deactivation of tachycardia therapies in order to avoid uncomfortable shocks at the end of life. From an ethical standpoint, deactivating an ICD to me seems no different to being documented as Not-for-Resuscitation. Deactivating a PPM, particularly in a pacemaker dependant patient probably requires a bit more discussion with patients and SDMs, but again would seem to me to fall under the umbrella of withdrawing life-sustaining treatment as opposed to actively ending someone’s life.
The first accompanying editorial by Butler and Puri was a better read, and a bit more emotive. It begins;
As he lay dying in a hospital in San Diego, a 71-year-old retired commercial fisherman was shocked 10 times by his implantable cardioverter-defibrillator (ICD), convulsing in front of his wife, 7 children, siblings, and mother. For 2 days, no medical professional intervened. The device was deactivated only at his wife’s insistence. Afterwards, she wanted to know, “Why wasn’t there a sticker on his chart? Why didn’t someone write that order?”
The editorialists go on to discuss the issue of the increasing number of devices being implanted and how these might impact on EoL care. They neatly sum up fragmentation of medical care (a problem encountered daily by intensivists, palliative medicine specialists, geriatrician and the few other generalists who happen to be left in the super-specialized hospital of the 21st century) and highlight the important of interprofessional communication.
The authors mention that only in 2010 did the Heart Rhythm Society state in a guideline that it was “ethically permissible” to deactiviate a device, and they wonder when anyone will state that it should be an “ethical responsibility” to inform patients that deactivation is an option. The authors conclude by postulating a way forward that involves increased training in communication skills and increased collaboration between cardiology and palliative medicine – a trend that is already occurring in many places.
One of the authors of the editorial, Katy Butler, has previously written on this issue from a very personal perspective in a New York Times Magazine article entitled “What Broke my Father’s Heart.” This article was quite moving and well worth a read. It’s always good to look at the health system from the perspective of a non-clinician, and Butler, a writer and teacher, does this eloquently and in a balanced manner.
Finally, in a really quite moving and inspirational editorial, Matlock and Mandrola highlight the fact that delivering caring end of life care is just good medicine and that early communication with patients is the key to preventing many issues and suffering that may result from conflicts at the end of life. With a couple of simple, to-the-point quotes they sum up the issue;
- CIEDs do not confer immortality.
- Death is not optional.
- Deactivating a pacemaker in a pacemaker-dependent patient is no different than withdrawing a ventilator from a ventilator-dependent patient.
All 4 articles are thought-provoking, well worth a read and eminently relevant to those working in critical care or, indeed, any aspect of acute medicine.