Heart Rhythm
Volume 7, Issue 11 , Pages 1537-1542, November 2010

Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: A quantitative assessment

  • Daniel B. Kramer, MD

      Affiliations

    • CardioVascular Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston Massachusetts
    • Corresponding Author InformationAddress reprint requests and correspondence: Dr. Daniel B. Kramer, Beth Israel Deaconess Medical Center, The CardioVascular Institute, Baker 4, 185 Pilgrim Road, Boston, Massachusetts 02446
    • ,
  • Aaron S. Kesselheim, MD, JD, MPH

      Affiliations

    • Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
    • ,
  • Dan W. Brock, PhD

      Affiliations

    • Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
    • ,
  • William H. Maisel, MD, MPH, FHRS

      Affiliations

    • CardioVascular Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston Massachusetts

Received 20 May 2010; accepted 13 July 2010. published online 21 July 2010.

Background

Despite the high prevalence of pacemakers and implantable cardioverter-defibrillators, little is known about physicians' views surrounding the ethical and legal aspects of managing these devices at the end of life.

Objective

The purpose of this study was to identify physicians' experiences and views surrounding the ethical and legal aspects of managing cardiac devices at the end of life.

Methods

Survey questions were administered to internal medicine physicians and subspecialists at a tertiary care center. Physicians were surveyed about their clinical experience, legal knowledge, and ethical beliefs relating to the withdrawal of PM and ICD therapy in comparison to other life-sustaining therapies.

Results

Responses were obtained from 185 physicians. Compared to withdrawal of PMs and ICDs, physicians more often reported having participated in the withdrawal or removal of mechanical ventilation (86.1% vs 33.9%, P <.0001), dialysis (60.6% vs 33.9%, P <.001), and feeding tubes (73.8% vs 33.9%, P <.0001). Physicians were consistently less comfortable discussing cessation of PMs and ICDs compared to other life-sustaining therapies (P <.005). Only 65% of physicians correctly identified the legal status of euthanasia in the United States, and 20% accurately reported the legal status of physician-assisted suicide in the United States. Compared to deactivation of an ICD, physicians more often characterized deactivation of a PM in a pacemaker-dependent patient as physician-assisted suicide (19% vs 10%, P = .027) or euthanasia (9% vs 1%, P <.001).

Conclusion

In this single-center study, internists were less comfortable discussing cessation of PM and ICD therapy compared to other life-sustaining therapies and lacked experience with this practice. Education regarding the legal and ethical parameters of device deactivation is needed.

Keywords: End-of-life care ethics, Implantable cardioverter-defibrillator, Pacemaker

Abbreviations: ICD, implantable cardioverter-defibrillator, PM, pacemaker

 

 This research was conducted with the support of a pilot grant from Harvard Catalyst The Harvard Clinical and Translational Science Center (NIH Grant 1-UL1-RR025758-02 and financial contributions from participating institutions). Dr. Kesselheim is supported by a career development award from the Agency for Healthcare Research and Quality (K08HS18465-01).

PII: S1547-5271(10)00709-5

doi:10.1016/j.hrthm.2010.07.018

Heart Rhythm
Volume 7, Issue 11 , Pages 1537-1542, November 2010

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