Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated?

Abstract

Cardiovascular implantable electronic devices (CIEDs) are common in the United States as treatment for cardiac rhythm problems. These devices can be life-sustaining. As patients age and suffer from worsening cardiac-related disorders and other terminal illnesses, the electrophysiology community can expect increased requests for device deactivation from patients and their surrogates, creating tension between competing ethical obligations to respect patient autonomy, on the one hand, and to promote patient well being (“beneficence”) and avoid harm (“nonmaleficence”), on the other. Response by Kay and Bittner on p 340 The ethical propriety of withdrawal of other similar life-sustaining treatments, such as ventilator support and implantable cardioverter-defibrillator (ICD) shock therapy, is now well established.1–3 Despite this, withdrawal of pacemaker therapy remains controversial. This report examines the sources of this controversy and supports the conclusion that there is no ethically significant difference between pacemaker therapy and other life-extending treatments and that requests for its withdrawal from competent informed patients or their surrogates should be honored. Because pacemaker therapy is discussed here in the context of life-sustaining therapy, the concepts apply mostly to pacemaker-dependent patients. Discussions regarding CIED therapy withdrawal should occur early in the patient’s care and should not be distinguished from other forms of life-saving treatment. In each case, the discussion should involve a determination of the patient’s goals and preferences, which are entitled to respect. In 2008, the American College of Cardiology, American Heart Association, and Heart Rhythm Society issued Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities (Guidelines).1 The Guidelines state that caregivers “generally make a distinction between deactivating a pacemaker and deactivating an ICD or CRT device.”1 Physicians are understandably uncomfortable when faced with a request for deactivation of pacing therapy provided to pacemaker-dependent patients whose death will likely ensue from their underlying disease. Allowing death to occur, …