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As End of Life Nears, What to Do With Implanted Defibrillators?
Date:5/14/2010

New guidelines help patients, doctors decide on removal to avoid unnecessary shocks

FRIDAY, May 14 (HealthDay News) -- Until now no guidelines existed for one of the more difficult questions in medicine -- what to do with a heart-assisting device, such as an implanted defibrillator, in a patient's final days of life?

An implanted defibrillator delivers a potentially life-saving electric shock to restart a heart that stops beating. However, the shock can cause acute discomfort in the last days of life, when the goal is to minimize pain, and in this case continued use of the devices may conflict with a patient's wishes.

Now, expert guidelines announced Friday at the meeting of the Heart Rhythm Society in Denver suggest that, whenever possible, terminally ill patients should be free to make their own decisions as to whether they'd like the devices removed.

"This is a situation we face more and more often," noted Dr. Rachel Lampert, associate professor of cardiology at Yale University School of Medicine. "As the population in hospices grows, the issue of how to manage defibrillators becomes more important."

Lampert is co-chair of a committee scheduled to present a consensus statement on the management of pacemakers, defibrillators and other cardiovascular implantable electronic devices. The statement will also be published in the July issue of HeartRhythm.

Few medical institutions have policies about deactivating electronic heart devices. A recent study of more than 400 hospices found that just 10 percent had guidelines about disconnecting implanted defibrillators.

"At Yale, we looked at our own population and found that up to 20 percent of patients with defibrillators got shocked in the weeks before death," Lampert said.

She worked with Dr. David Hayes of the Mayo Clinic, Rochester, Minn., in assembling a committee to consider guidelines for the issue. "We put together a group of individuals with expertise in different areas," Lampert said. "It included an ethicist, a lawyer, a nurse and a psychiatrist."

The purpose of the statement "is to carry out a patient's wish to provide or withdraw therapy as the patient desires," said Dr. Richard Page, professor and chair of medicine at the University of Wisconsin and president of the Heart Rhythm Society.

Removing an implanted defibrillator near the end of life, "is not physician-assisted suicide or euthanasia," he stressed.

The statement, developed in cooperation with other organizations, including the American College of Cardiology and the American Heart Association, recommends above all that all patients with implanted electronic devices be encouraged to make advance directives.

"Ideally, you have the conversation and make the patient aware of his or her empowerment and what decision should be made before you get to this point," Page said.

Other provisions of the consensus statement:

  • All adult patients are assumed to be competent to make decisions on continuing or stopping treatment. When a patient lacks capacity, the decision can be made by a designated health care proxy.
  • Physicians or other caregivers cannot be compelled to carry out a procedure that conflicts with their ethical values. In such a case, the issue can be passed to a colleague who is willing to carry out the task.
  • The recommendations will give physicians and institutions a frame of reference, experts said. "At least now you have a consensus statement based on a number of perspectives and a literature review to provide guidance," Page said.

More information

To learn more about defibrillators, go to the U.S. National Heart, Lung, and Blood Institute.



SOURCES: Rachel Lampert, M.D., F.H.R.S., associate professor, cardiology, Yale University, New Haven, Conn.; Richard Page, M.D., professor and chair, medicine, University of Wisconsin, Madison, and President, Heart Rhythm Society; May 14, 2010, Heart Rhythm Society annual meeting, Denver; July 2010 HeartRhythm


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