HRJ: Internal med docs are uncomfortable deactivating ICDs

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A majority of physicians are not comfortable conducting end-of-life discussions about deactivating pacemakers and implantable cardioverter-defibrillators (ICDs), compared with other life-sustaining therapies, such as mechanical ventilation, according to a survey published in the November edition of Heart Rhythm Journal.

The results uncover a need for more education regarding the legal and ethical parameters guiding cessation of pacemaker and ICD therapy, according to the study, conducted by Daniel B. Kramer, MD, and colleagues at Beth Israel Deaconess Medical Center in Boston.

"Despite the effectiveness of heart rhythm devices, clinical studies demonstrate 5 to 20 percent annual mortality rates for recipients, meaning that tens of thousands of deaths occur annually among these patients," the authors wrote.

They added: "All physicians should understand that patients with decision-making capacity have the right to refuse interventions or to ask that therapies be withheld or withdrawn, regardless of the therapy in question or the consequences of stopping treatment."

The study, commissioned earlier this year with support from the Harvard Catalyst program, explored the experience, legal knowledge and ethical views of 185 respondents (out of 746 emailed questionnaires) at Beth Israel.

Among the responders who provided professional training data, nearly all were trained as internists (98 percent), and most practiced at the level of clinical attending. Among the physicians reporting additional subspecialty training, the most common fields were cardiology (8.5 percent), pulmonary/critical care (8.5 percent) and geriatrics (5.2 percent).

Kramer and colleagues found that compared to withdrawal of pacemakers and ICDs, physicians more often reported having participated in the withdrawal or removal of mechanical ventilation (86 vs. 34 percent), dialysis (60 vs. 34 percent) and feeding tubes (73 vs. 34 percent). All differences were significant.

The survey found that only 65 percent of physicians correctly identified the legal status of euthanasia in the U.S., and 20 percent accurately reported the legal status in the U.S. of physician-assisted suicide.

Researchers found that 25 to 49 percent of physicians considered deactivation of pacemakers and ICDs to be morally distinct from the withdrawal of other life-sustaining therapies. Compared to deactivation of an ICD, physicians more often characterized deactivation of a pacemaker in a pacemaker-dependent patient as physician-assisted suicide or euthanasia.

Only about one-third of physicians were aware that neither the presence of a terminal illness nor an underlying heart rhythm influences the legality of pacemaker deactivation.

Nearly half of respondents strongly agreed that patient care would be improved by national guidelines addressing the appropriate time for cardiac device deactivation in end-of-life patients.

In July, the Heart Rhythm Society published guidelines in its journal for the management of cardiac devices in patients at the end of their lives or requesting withdrawal of device therapy.

"Given the broadening use of these devices in an aging American population, it is critical that physicians from different specialties work together and with their patients to understand these issues. Advanced care planning is essential, but this presupposes an appreciation of the clinical options that are ethical and legal under different circumstances," said Kramer.

This topic also can be disconcerting for electrophysiologists. A study last year of heart rhythm specialists with substantial personal experience deactivating devices suggested that, despite frequently performing deactivations, many remained uncomfortable with the practice and favored involvement of psychiatric and/or ethics consultations (Circ Arrhythm Electrophysiol 2009;2:340-344).