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26-03-2013 | Cardiology | Article

ICD switch-off a gray area for clinicians


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medwireNews: The deactivation of an implantable cardioverter defibrillator (ICD) should not be done against the wishes of a patient or their family and surrogates, even when continuing the treatment is medically futile, a survey of electrophysiology (EP) practitioners suggests.

Of those surveyed, 43% believed that ICDs are unlike other medical interventions, comparing them variously to external defibrillation, dialysis, and coronary stents. By contrast, 50% of the EP practitioners considered pacemakers to be constitutive therapy - therapy that keeps a patient alive, such as dialysis - and more than 80% indicated that the deactivation of a pacemaker was ethically and/or morally different to deactivating the shocking function of an ICD.

"There was a mixed response regarding the ethical nature of ICDs and the justification for deactivating them in end-of-life situations," lead researcher James Kirkpatrick (University of Pennsylvania, Philadelphia, USA) said in a press release.

Overall, most "did not believe ICDs fit into any of our currently accepted categories for types of therapies we withdraw, such as mechanical ventilation," he added.

Presenting their data at the 2013 American College of Cardiology meeting in San Francisco, California, the researchers reported on 383 EP doctors, nurses, and technicians surveyed in order to understand the ethical considerations of ICD deactivation.

The majority (73%) stated that deactivating the ICD shock function was not ethically/morally different to withholding cardiopulmonary resuscitation (CPR) or coded external defibrillation, although 83% felt that it was different from deactivating pacing in a pacemaker-dependent patient.

"When asked if deactivation of ICD shock function in agreement with patient wishes and a pre-existing DNR [do not resuscitate] order constituted physician assisted suicide, the vast majority answered 'no,' " according to the researchers.

Seventy-seven percent of the EP providers felt it was not ethical or moral to deactivate an ICD against a patient's or family's wishes, even in the setting of medical futility.

"Based on these findings we need to further explore ways to help clinicians address end-of-life management of ICDs," Kirkpatrick stated.

By medwireNews Reporters

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