Study puts defibrillator implants into ethical context
By Adela Talbot
December 13, 2012
When it comes to confronting unrelated end-of-life issues, implantable cardioverter defibrillators (ICDs) aren’t right for every patient, and may, in fact, do more harm than good.
The small, battery-powered defibrillators are increasingly implanted in individuals at risk of sudden cardiac death. However, for some patients, the devices should be turned off or left with drained batteries, according to a group of researchers led by Western’s Lorne Gula, Department of Epidemiology and Biostatistics in the Schulich School of Medicine & Dentistry.
In Ethical and Legal Perspective of Implantable Cardioverter Defibrillator Deactivation or Implantable Cardioverter Defibrillator Generator Replacement in the Elderly, a new paper co-authored by Gula, researchers indicate the issue becomes one of ethics when dealing with elderly patients suffering from other ailments or conditions – such as cancer – that could take their life before a cardiac arrest.
According to the paper, one in five patients with an ICD gets multiple painful shocks in the last few weeks of life. For individuals already suffering from other ailments, this takes away from the patient’s quality of life, Gula explained.
ICDs are relatively common, Gula noted, and while doctors are reluctant to discuss end-of-life planning with patients who have ICDs, it is best for them to inform patients during the initial consultation about the possibility of deactivating the device.
“Patients have a right to make the final decision on their care plan and issues that involve their ICD, and most of them choose to be very involved,” he said.
“It is often the elderly patient with a new illness, since ICD implant, brings to our attention that the ICD is not something they wish to continue with. Perhaps they have received shocks in the past and the prospect of future shocks causes more anxiety than comfort in the context of a poor prognosis from other illnesses.”
What’s more, for the elderly ailing patient, the risks associated with a surgical procedure to replace the ICD battery outweigh the benefits and could lead to additional complications that previously did not cause a problem. It is up to doctors to inform patients of the risks, benefits and options available.
“Discussions around end-of-life issues are sensitive and can be challenging. It is important that the patient has time to reach a decision that best suits their outlook,” Gula said. “The ICD does give several months’ notice before battery change is required, allowing for these discussions and considerations to take place. It is up to us as physicians to facilitate this process.”
At the end, it’s the informed decision of the patient that must be respected, and a conversation doctors shouldn’t fear having.
“Opinions on goals of care and best therapeutic choices can vary within a family. This can often be overcome with communication and ensuring that the main focus is on the patient’s wishes. We encourage discussion and communication, and ultimately the instructions of the patient or their designated caregiver need to be respected,” Gula explained.
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