OBJECTIVE
To determine the opinions of medical professionals, legal professionals, and patients
regarding the withdrawal of implantable cardioverter-defibrillator (ICD) and pacemaker
therapy at the end of life.
PARTICIPANTS AND METHODS
A survey regarding 5 cases that focused on withdrawal of ICD or pacemaker therapy
at the end of life was constructed and sent to 5270 medical professionals, legal professionals,
and patients. The survey was administered from March 1, 2008, to March 1, 2009.
RESULTS
Of the 5270 recipients of the survey, 658 (12%) responded. In a terminally ill patient
requesting that his ICD be turned off, most legal professionals (90% [63/70]), medical
professionals (98% [330/336]), and patients (85% [200/236]) agreed the ICD should
be turned off. Most legal professionals (89%), medical professionals (87%), and patients
(79%) also considered withdrawal of pacemaker therapy in a non–pacemaker-dependent
patient appropriate. However, significantly more legal (81%) than medical professionals
(58%; P<.001) or patients (68%, P=.02) agreed with turning off a pacemaker in the pacemaker-dependent patient. A similar
number of legal professionals thought turning off a device was legal regardless of
whether it was an ICD or pacemaker (45% vs 38%; P=.50). However, medical professionals were more likely to perceive turning off an
ICD as legal than turning off a pacemaker (85% vs 41%; P<.001).
CONCLUSION
Most respondents thought device therapy should be withdrawn if the patient requested
its withdrawal at the end of life. However, opinions of medical professionals and
patients tended to be dependent on the type of device, with turning off ICDs being
perceived as more acceptable than turning off pacemakers, whereas legal professionals
tended to perceive all devices as similar. Thus, education and discussion regarding
managing devices at the end of life are important when having end-of-life discussions
and making end-of-life decisions to better understand patients' perceptions and expectations.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Mayo Clinic ProceedingsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
In re Quinlan, 70 NJ 10, 355 A.2d 647 (1976). New Jersey Supreme Court. Health Law and Bioethics: Cases in Context Web site. http://aspen.skeeydev.net/books/johnsonkrause/INREQUINLANSupremeCourtofNewJersey.doc. Accessed August 24, 2010.
Cruzan by Cruzan v. Director, Missouri Dept of Health, 497 US 261. 88-1503. (1990). Supreme Court of the United States. Cornell Legal Information Institute Web site. http://www.law.cornell.edu/supct/html/historics/USSC_CR_0497_0261_ZS.html. Accessed August 24, 2010.
- “Culture of life” politics at the bedside—the case of Terri Schiavo.N Engl J Med. 2005; 352: 1710-1715
- The Rights of Patients: The Authoritative ACLU Guide to the Rights of Patients. 3rd ed. Southern Illinois University Press, Carbondale, IL2004
- Management of implantable cardioverter defibrillators in end-of-life care.Ann Intern Med. 2004; 141: 835-838
- The ethics of deactivating implanted cardioverter defibrillators.Ann Intern Med. 2005; 142: 631-634
- Withdrawing implantable defibrillator shock therapy in terminally ill patients.Am J Med. 2006; 119: 892-896
- Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life.Mayo Clin Proc. 2003; 78: 959-963
- Deactivating implanted cardiac devices in terminally patients: practices and attitudes.Pacing Clin Electrophysiol. 2008; 31: 560-568
- Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians [letter].J Am Coll Cardiol. 2009; 54: 371-373
- Discontinuing an implantable cardioverter defibrillator as a life-sustaining treatment.Am J Cardiol. 1994; 74: 205-207
- Withdrawal of cardiac medications and devices.AACN Adv Crit Care. 2007; 18: 415-425
- Physicians' preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator.Mayo Clin Proc. 2008; 83: 1139-1141
- Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated? Deactivating permanent pacemaker in patients with terminal illness. Patient autonomy is paramount.Circ Arrhythm Electrophysiol. 2009; 2: 340-344
- Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated? Deactivating implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness. An ethical distinction.Circ Arrhythm Electrophysiol. 2009; 2: 336-339
- HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIED) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm Online.(Accessed August 24, 2010.)
- “That's like an act of suicide” patients' attitudes toward deactivation of implantable defibrillators.J Gen Intern Med. 2008; 23: 7-12
- Advance health planning and treatment preferences among recipients of implantable cardioverter defibrillators: an exploratory study.J Clin Ethics. 2006; 17: 72-78
- When is deactivation of artificial pacing and AICD illegal, immoral and unethical?.Am J Geriatr Cardiol. 2003; 12: 275-276
- Cardiac pacemakers and implantable defibrillators in terminal care.J Pain Symptom Manage. 1999; 18: 126-131
Vacco, Attorney General of New York et al. v Quill et al. 521 US 793. 95-1858. (1997). Supreme Court of the United States. Cornell Legal Information Institute Web site. http://www.law.cornell.edu/supct/html/95-1858.ZS.html. Accessed August 24, 2010.
- Seven legal barriers to end-of-life care: myths, realities, and grains of truth.JAMA. 2000; 284: 2495-2501
- Palliative care.N Engl J Med. 2004; 350: 2582-2590
- Ethics manual: fifth edition.Ann Intern Med. 2005; 142: 560-582
- Withdrawing very low-burden interventions in chronically ill patients.JAMA. 2000; 283: 1061-1063
- Code of Medical Ethics: Current Opinions and Annotations 2008-2009. AMA Council on Ethical and Judicial Affairs. AMA Press, Chicago, IL2010
- Physician Objection to Treatment and Individual Patient Discrimination: CEJA Report 6-A-07. AMA Press, Chicago, IL2007: 1-4
- The Silent World of Doctor and Patient. The Johns Hopkins University Press, Baltimore, MD2002
- Four models of the physician-patient relationship.JAMA. 1992; 267: 2221-2226
Article Info
Footnotes
Survey development and statistical analysis were supported in part by a grant from the Mayo Clinic Program in Professionalism and Ethics.
An earlier version of this article appeared Online First.
Supporting Online Material
www.mayoclinicproceedings.com/content/85/11/981/suppl/DC1
eAppendix 1
eAppendix 2
Identification
Copyright
© 2010 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
