WASHINGTON — 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. View the full study.
The study, commissioned in early 2010 with support from the Harvard Catalyst program, explored the experience, legal knowledge and ethical views of 185 respondents at Beth Israel Deaconess Medical Center, an academic tertiary center in Boston, 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.”
To address the existing need for more comprehensive guidelines and education on the issue, the Heart Rhythm Society published: The HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. The guidelines were presented at Heart Rhythm 2010, the Heart Rhythm Society’s Annual Scientific Sessions, and published in the July edition of HeartRhythm. 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.
For more information about this study, please visit www.heartrhythmjournal.com.
About the Heart Rhythm Society
The Heart Rhythm Society is the international leader in science, education and advocacy for cardiac arrhythmia professionals and patients, and the primary information resource on heart rhythm disorders. Its mission is to improve the care of patients by promoting research, education and optimal health care policies and standards. Incorporated in 1979 and based in Washington, DC, it has a membership of more than 5,300 heart rhythm professionals in more than 72 countries around the world. www.HRSonline.org
About HeartRhythm Journal
HeartRhythm provides rapid publication of the most important science developments in the field of arrhythmias and cardiovascular electrophysiology (EP). As the official journal of the Heart Rhythm Society, HeartRhythm publishes both basic and clinical subject matter of scientific excellence devoted to the EP of the heart and blood vessels, as well as therapy. The journal is the only EP publication serving the entire electrophysiology community from basic to clinical academic researchers, private practitioners, technicians, industry and trainees. HeartRhythm Journal has an impact factor of 4.559 (as of 2010) and ranks 11th out of 78 cardiovascular medicine journals worldwide by the Institute for Scientific Information, remaining the number one specialty journal in cardiology. It is also the official publication of the Cardiac Electrophysiology Society.
Contact: Kennesha Baldwin
Heart Rhythm Society