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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. We investigated whether electrophysiology practitioners believes medical futility justifies unilateral ICD deactivation.
Email invitations to take an online survey were sent to 1,894 EP practitioners. There were 32 inaccurate addresses. 384 responses were collected (response rate 20.6%). Mean age was 48 (range 26-76); 80% were male; 74.6% Caucasian, 15.0% Asian, 5.5% Latino, 1.3% Black/African American. 64.0% academically affiliated; 78.7% from North America, 10.2% Europe, 5.0% Asia, 3.1% Australia, 2.6% South America and 0.3% Africa; 67.8% urban, 27.2% suburban and 5% rural.
A plurality (165/383, 43.0%) regarded ICD's to be unlike any other intervention (compared to “applied therapy like external defibrillation”–24.2%; “constitutive therapy that keeps patient alive, like dialysis”–13.3%; “implant that becomes part of the body, like a coronary stent”–12.0%). Half of respondents, by contrast, considered pacemakers to be “constitutive therapy” (191/382, 50%). A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding CPR or external defibrillation in a code (72.7%, 277/381) but was different than deactivating pacing in a pacemaker-dependent patient (83.0%, 318/383). When asked if deactivation of ICD shock function in agreement with patient wishes and a pre-existing DNR order constituted physician assisted suicide, the vast majority answered, “no” (371/382, 97%). However, a majority responded that it was not ethical/moral for doctors to deactivate ICDs against patients’ wishes (77.4%, 296/382) or against family/surrogates’ wishes (72.6%, 278/383), even in the setting of medical futility.
This international sample considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not deemed ethical/moral.
Poster Sessions, Expo North
Monday, March 11, 2013, 9:45 a.m.-10:30 a.m.
Session Title: Arrhythmias: Devices IV – Ethical and Economic Issues Related to Arrhythmia Devices
Abstract Category: 8. Arrhythmias: Devices
Presentation Number: 1277-28
- 2013 American College of Cardiology Foundation