HRS: Statement guides end-of-life ICD withdrawal requests

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DENVER—The Heart Rhythm Society issued a collaborative expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing the end of life or requesting a withdrawal of their therapy during its 31st annual conference.

The authors, led by Rachel Lampert, MD, from Yale University School of Medicine in New Haven, Conn., and David L. Hayes, MD, at Mayo Clinic in Rochester, N.Y., wrote that the goals of the document are:

  • To make clinicians aware of the legal, ethical and religious principles, which underlie withdrawal of life-sustaining therapies, including device deactivation, in patients who have made this decision;
  • To highlight the importance of proactive communication by the clinician to minimize suffering as the end of life nears for patients with CIEDs; and
  • To provide a management scheme to guide the clinician in assisting a patient with a request to withdraw CIED therapy.

“We hope the statement will impact practice in ways that will improve quality of life for patients and decrease any confusions and uncertainties for physicians,” Lambert said in today’s press conference.

Specifically, the document addresses common ethical and legal concerns related to withdrawing CIED therapies, including whether withdrawing the CIED therapy is akin to assisted suicide or euthanasia; whether there are unique factors of CIED therapy, such as continuity, duration and integration within the body, that differentiate it from other therapies; or if a patient requests a surgical removal of the his/her generator.

The document goes into depth about the difference between allowing a patient to withdraw from life-sustaining therapies and physician-assisted suicides, as defined by the U.S. Supreme Court.

“This is an issue that impacts many different healthcare providers, not only electrophysiologists and pediatric electrophysiologists, but also other specialties, including geriatrics and internal medicine, who were all represented on the writing panel,” said Lambert, who added that they also consulted lawyers and ethical experts.

“Many caregivers are highly involved with end-of-life care, and this document should assist them as well,” she said.

In addition to the ethical and legal considerations, the document also addresses the issue of “effectively putting into practice the device deactivation process,” which heavily focuses on the communications of goals, options, timing of conversations, alternatives, and the role of the provider in the decision making process.

The document, which was developed in collaboration with the American College of Cardiology, the American Geriatrics Society, the American Academy of Hospice and Palliative Medicine, the American Heart Association and the European Heart Rhythm Association, will be published in the July issue of the HeartRhythm Journal.