Abstract 9923: The Ethics of Unilateral ICD and CRT-D Deactivation: Patient Perspectives

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Margaret G Daeschler ◽  
Ralph J Verdino ◽  
James N Kirkpatrick
Keyword(s):  
Assisted Suicide ◽  
Medical Center ◽  
Medical Futility ◽  
Cardiac Resynchronization ◽  
Implantable Cardioverter Defibrillators ◽  
Physician Assisted Suicide ◽  
Do Not Resuscitate ◽  
Device Management ◽  
Advanced Directives ◽  
Advance Care

Background: Decisions about deactivation of implantable cardioverter defibrillators (ICDs) are complicated. Unilateral Do-Not-Resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. Unilateral deactivation of ICDs may be seen as a logical extension of a unilateral DNR order. Methods: 60 respondents who had an ICD or cardiac resynchronization therapy ICD (CRT-D) were interviewed at a quaternary medical center outpatient electrophysiology practice. Survey questions addressed the inclusion of ICD deactivation in advanced directives, whether ICD deactivation constitutes physician-assisted suicide, and whether unilateral ICD deactivation can be ethically justified. The average age was 59 (range 23-89), and 70% were male. Of the respondents, 35% had ICDs, and 65% had CRT-Ds. Respondents had had their devices for an average of 6.74 years (range 0.11-25). 82% of respondents were Caucasian, 15% were African American and 3% were Hispanic. Results: Only 15% of patients had thought about device deactivation if they were to develop a serious illness from which they were not expected to recover, and single respondents were more likely to have considered this point (38%, p=0.03). A small majority (53%) had advance directives, and only one mentioned what to do with the device. Only 3% had discussed device management with clinicians. Most (55%) believed turning off a patient’s pacemaker was no different than not performing CPR or administering external defibrillation. A majority (77%) did not consider device deactivation in accordance with patient wishes to be physician-assisted suicide. A majority (78%) responded that it was not ethical/moral for doctors to deactivate ICDs against patients’ wishes. Conclusion: In an era of cost-consciousness and scrutiny of resources, management of ICDs and CRT-Ds as patients near the end of their lives create ethical dilemmas. Few patients consider device deactivation at end of life, though a large majority believes that unilateral deactivation is not ethical or moral, even in the setting of medical futility. Advance care planning for these patients should address device deactivation.

Requests for euthanasia and physician-assisted suicide and the availability and application of palliative options

2006 ◽  
Vol 4 (4) ◽  
pp. 399-406 ◽  
Author(s):  
MARIJKE C. JANSEN-VAN DER WEIDE, ◽  
BREGJE D. ONWUTEAKA-PHILIPSEN ◽  
GERRIT VAN DER WAL
Keyword(s):  
Decision Making ◽  
Observational Study ◽  
General Practitioners ◽  
Assisted Suicide ◽  
Medical Futility ◽  
Physician Assisted Suicide

Objective: This study investigated the palliative options available when a patient requested euthanasia or physician-assisted suicide (EAS), the extent to which the options were applied, and changes in the patient's wishes.Methods: In an observational study, 3614 general practitioners (GPs) filled in a questionnaire and described their most recent request for EAS (if any) (n = 1,681).Results: Palliative options were still available in 25% of cases. In these cases options were applied in 63%; in 46% of these cases patients withdrew their request. Medication other than antibiotics, which was most frequently mentioned as a palliative option (67%), and applied most frequently (79%), together with radiotherapy, most frequently resulted in patients withdrawing their request.Significance of results: GPs include the availability of palliative options in their decision making when considering EAS. The fact that not all options are applied or, if applied, the patient persists in the request is related to autonomy of the patient, the burden on the patient, and medical futility of the option.

Initial Experience of an Anesthesiology-based Service for Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators

2015 ◽  
Vol 123 (5) ◽  
pp. 1024-1032 ◽  
Author(s):  
G. Alec Rooke ◽  
Stefan A. Lombaard ◽  
Gail A. Van Norman ◽  
Jörg Dziersk ◽  
Krishna M. Natrajan ◽  
...  
Keyword(s):  
Medical Center ◽  
Strong Support ◽  
Retrospective Chart Review ◽  
High Volume ◽  
Management Plan ◽  
Implantable Cardioverter Defibrillators ◽  
Device Management ◽  
Number Of Patients ◽  
Cardioverter Defibrillators ◽  
Over Time

Abstract Background Management of cardiovascular implantable electronic devices (CIEDs), including pacemakers and implantable cardioverter defibrillators, for surgical procedures is challenging due to the increasing number of patients with CIEDs and limited availability of trained providers. At the authors’ institution, a small group of anesthesiologists were trained to interrogate CIEDs, devise a management plan, and perform preoperative and postoperative programming and device testing whenever necessary. Methods Patients undergoing surgery between October 1, 2009 and June 30, 2013 at the University of Washington Medical Center were included in a retrospective chart review to determine the number of devices actively managed by the Electrophysiology/Cardiology Service (EPCS) versus the Anesthesiology Device Service (ADS), changes in workload over time, surgical case delays due to device management, and errors and problems encountered in device programming. Results The EPCS managed 254 CIEDs, the ADS managed 548, and 227 by neither service. Over time, the ADS providers managed an increasing percentage of devices with decreasing supervision from the EPCS. Only two CIEDs managed by the ADS required immediate assistance from the EPCS. Patients who were unstable postoperatively were referred to the EPCS. Although numerous issues in programming were encountered, primarily when restoring demand pacing after programming asynchronous pacing for surgery, no patient harm resulted from ADS or EPCS management of CIEDs. Conclusions An ADS can provide safe CIED management for surgery, but it requires specialized provider training and strong support from the EPCS. Due to the complexity of CIED management, an ADS will likely only be feasible in high-volume settings.

The Right to Privacy and the Right to Die

2000 ◽  
Vol 17 (2) ◽  
pp. 276-292 ◽  
Author(s):  
Tom L. Beauchamp
Keyword(s):  
Twentieth Century ◽  
New Jersey ◽  
Assisted Suicide ◽  
Right To Die ◽  
Physician Assisted Suicide ◽  
Do Not Resuscitate ◽  
Medical Technologies ◽  
The Right To Privacy ◽  
To Come ◽  
The Right

Western ethics and law have been slow to come to conclusions about the right to choose the time and manner of one's death. However, policies, practices, and legal precedents have evolved quickly in the last quarter of the twentieth century, from the forgoing of respirators to the use of Do Not Resuscitate (DNR) orders, to the forgoing of all medical technologies (including hydration and nutrition), and now, in one U.S. state, to legalized physician-assisted suicide. The sweep of history—from the Quinlan case in New Jersey to legislation in Oregon that allows physician-assisted suicide—has been as rapid as it has been revolutionary.

Euthanasia and Related Practices Worldwide

Crisis ◽  
1998 ◽  
Vol 19 (3) ◽  
pp. 109-115 ◽  
Author(s):  
Michael J Kelleher † ◽  
Derek Chambers ◽  
Paul Corcoran ◽  
Helen S Keeley ◽  
Eileen Williamson
Keyword(s):  
Assisted Suicide ◽  
International Association ◽  
Active Euthanasia ◽  
Physician Assisted Suicide ◽  
Passive Euthanasia ◽  
Medical Practitioners ◽  
General Acceptance ◽  
International Importance ◽  
Controversial Area ◽  
Active And Passive Euthanasia

The present paper examines the occurrence of matters relating to the ending of life, including active euthanasia, which is, technically speaking, illegal worldwide. Interest in this most controversial area is drawn from many varied sources, from legal and medical practitioners to religious and moral ethicists. In some countries, public interest has been mobilized into organizations that attempt to influence legislation relating to euthanasia. Despite the obvious international importance of euthanasia, very little is known about the extent of its practice, whether passive or active, voluntary or involuntary. This examination is based on questionnaires completed by 49 national representatives of the International Association for Suicide Prevention (IASP), dealing with legal and religious aspects of euthanasia and physician-assisted suicide, as well as suicide. A dichotomy between the law and medical practices relating to the end of life was uncovered by the results of the survey. In 12 of the 49 countries active euthanasia is said to occur while a general acceptance of passive euthanasia was reported to be widespread. Clearly, definition is crucial in making the distinction between active and passive euthanasia; otherwise, the entire concept may become distorted, and legal acceptance may become more widespread with the effect of broadening the category of individuals to whom euthanasia becomes an available option. The “slippery slope” argument is briefly considered.

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