WASHINGTON, November 9, 2010 — According to a new survey, physicians were significantly less comfortable discussing withdrawal of pacemaker (PM) and implantable cardioverter-defibrillator (ICD) therapy compared with other life-sustaining therapies, with approximately half stating that they were not comfortable having these conversations with patients. Similarly, physicians were almost twice as likely to have been involved in withdrawal of therapies such as mechanical ventilation and hemodialysis compared with cardiac devices. The survey, published in the November edition of HeartRhythm , the official journal of the Heart Rhythm Society, uncovers a need for more education regarding the legal and ethical parameters guiding cessation of PM and ICD therapy.
The study, commissioned in early 2010 with support from the Harvard Catalyst program, explored the experience, legal knowledge and ethical views of 185 respondents atBethIsraelDeaconessMedicalCenter, an academic tertiary center inBoston,Mass.Among the responders who provided professional training data, nearly all were trained as internists (98%), and most practiced at the level of clinical attending. Among the physicians reporting additional subspecialty training, the most common fields were cardiology (8.5%), pulmonary/critical care (8.5%) and geriatrics (5.2%).
Key findings from survey:
- Physicians were consistently less comfortable discussing cessation of PMs and ICDs compared to other life-sustaining therapies including ventilation, feeding tubes and dialysis.
- Compared to withdrawal of PMs and ICDs, physicians more often reported having participated in the withdrawal or removal of mechanical ventilation (86.1% vs. 33.9%), dialysis (60.6% vs. 33.9%) and feeding tubes (73.8% vs. 33.9%).
- 25% to 49% of physicians considered deactivation of PMs and ICDs to be morally distinct from the withdrawal of other life-sustaining therapies. Compared to deactivation of an ICD, physicians more often characterized deactivation of a PM in a pacemaker-dependent patient as physician-assisted suicide (19% vs. 10%) or euthanasia (9% vs. 1%).
- Only about one-third of physicians were aware that neither presence of a terminal illness or an underlying heart rhythm influences the legality of pacemaker deactivation.
- Nearly half (46%) strongly agreed that patient care would be improved by national guidelines addressing the appropriate time for cardiac device deactivation in end-of-life patients.
“Our survey sheds light on important gaps in physician experience and knowledge regarding the legal and ethical underpinnings of life-sustaining therapies, most notably cardiac devices,” said lead author Daniel B. Kramer, MD, Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Mass. “Given the broadening use of these devices in an aging American population, it is critical that physicians from different specialties work together and with their patients to understand these issues. Advanced care planning is essential, but this presupposes an appreciation of the clinical options that are ethical and legal under different circumstances.”
The expert consensus statement offers clinicians and industry guidance on the management of cardiac devices in patients at the end of their lives or requesting withdrawal of device therapy.
The November issue of HeartRhythm has a special focus on medical devices, highlighting the emerging trends and technologies of PMs, ICDs, left ventricular assist devices (LVADs) and cardiac resynchronization therapy devices (CRT-Ds).This study is one of the many included in the November edition that covers topics related to medical devices.