Consensus Issued on End-of-Life Cardiac Device Deactivation
DENVER — The first-ever consensus statement on management of cardiovascular implantable electronic devices in patients requesting treatment withdrawal near the end of life has been released by the Heart Rhythm Society in collaboration with other medical groups.
The expert consensus document provides physicians with practical guidance on how to effectively and proactively communicate with patients and families regarding device switch off, a situation many clinicians are uncomfortable with.
“Most clinicians and industry-employed allied professionals who primarily interact with patients with CIEDs [cardiovascular implantable electronic devices] have cared for dying patients and have participated in device deactivations. However, the understanding of device deactivation varies, and studies show that many physicians report uneasiness with conversations addressing device management as patients near the end of their lives,” Dr. Rachel Lampert explained in introducing the new document at the meeting.
The consensus document, created by a multidisciplinary panel, delves into the legal, ethical, and religious principles underlying the withdrawal of life-sustaining cardiac devices, added Dr. Lampert, lead author and an electrophysiologist at Yale University, New Haven, Conn.
Co-lead author Dr. David L. Hayes, professor of medicine at the Mayo Clinic, Rochester, Minn., noted that the document spells out the logistics involved in device deactivation in a way that's meant to serve as a template. Every hospital and all physicians who implant CIEDs ought to have in place a clear process for device withdrawal.
Among the key points made in the document were:
▸ A patient has the legal right to refuse or request withdrawal of any medical treatment or intervention, even if not terminally ill.
▸ Carrying out a request to withdraw life-sustaining therapy does not constitute physician-assisted suicide or euthanasia in any ethical or legal sense.
▸ A physician who views device deactivation as incompatible with his or her personal values is not obligated to carry out the procedure, but should involve a colleague who is willing to do so. Abandoning the patient is unacceptable.
Dr. Lampert noted that surveys indicate about 10% of physicians feel it's wrong to turn off a pacemaker. A smaller percentage feels similarly about switching off an ICD.
The expert consensus document was published in the July issue of HeartRhythm (2010;7:1008-26).
Disclosures: Dr. Lampert disclosed serving as a consultant to Boston Scientific Corp. and Medtronic Inc. Dr. Hayes is also a consultant to those companies, and to St. Jude Medical Inc. as well.
