An article recently published on msnbc.com discussed the use of implanted cardioverter-defibrillators (also known as ICDs) in patients at the end of their life, and how while the device can be useful in saving a life, it can be traumatic when the device continues to be used in a dying patient. It is estimated that 250,000-300,000 ICDs are implanted in patients each year who are at risk for sudden cardiac arrest. However, for a dying patient, delivering multiple shocks to a heart that is failing is not only painful for the patient, but painful for a family to witness, especially if they are unprepared for such an event. Patient examples were noted, including a hospice patient who received 33 shocks from the ICD while they lay dying in the arms of a loved one. Another example was given of a woman whose father was no longer breathing, but whose body was "jumping" around the bed as his ICD continued to deliver shocks (Carroll).
It is suggested that many physicians do not discuss with their patients or patient's family the option of turning-off the ICD, or reprogramming it to be more like a pacemaker, so the patient either receives small, undetectable shocks or no shock at all. It is suggested that physicians are uncomfortable when faced with deactivation because they are allowing death to occur faster than if the device was still functioning normally. It was also stated that some physicians feel they are performing either physician-assisted suicide or euthanasia when turning off an ICD at the request of a patient (Zellner).
Guidelines for device-based therapy do not imply that deactivation is unethical, but do state the ICDs and pacemakers that are requested to be deactivated by the patient be honored. While the use of an ICD or pacemaker prolongs a patient's life, it does not cure the existing cardiac problem. The physician is also not introducing a new pathology as the cause of death of a patient, but they allow an existing disease to complete its natural history without interruption from an ICD (Zellner).
I feel that a physician is morally and ethically obligated to ensure their patient and their family is educated as to the function of the device, including how the device will act as the patient's health declines. I also feel that if a patient requests their device be deactivated, the physician either grants the request, or refers their patient to another physician who can. But when should a physician provide this education/counseling to patients and their family? At the time the device is inserted, or as the patient nears the end of their life? If you wait too long to provide support, are you telling the patient and their family that it's time to give up and there's no hope left?
Carroll, Linda. "Shocking Ending: Implanted Defibrillators can bring misery to final hours. http://vitals.msnbc.msn.com/news/2011/10/07/8212715-shocking-ending-implanted-defibrillators-can-bring-misery-to-final-hours
Zellner, Richard, Aulisio, Mark, and Lewis, William. "Should implanatable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated?". Circulation: Arrhythmia and Electrophysiology. 2009; 2: 340-344 Controversies in Arrhythmia and Electrophysiology. http://circep.ahajournals.org/content/2/3/340.full
It is suggested that many physicians do not discuss with their patients or patient's family the option of turning-off the ICD, or reprogramming it to be more like a pacemaker, so the patient either receives small, undetectable shocks or no shock at all. It is suggested that physicians are uncomfortable when faced with deactivation because they are allowing death to occur faster than if the device was still functioning normally. It was also stated that some physicians feel they are performing either physician-assisted suicide or euthanasia when turning off an ICD at the request of a patient (Zellner).
Guidelines for device-based therapy do not imply that deactivation is unethical, but do state the ICDs and pacemakers that are requested to be deactivated by the patient be honored. While the use of an ICD or pacemaker prolongs a patient's life, it does not cure the existing cardiac problem. The physician is also not introducing a new pathology as the cause of death of a patient, but they allow an existing disease to complete its natural history without interruption from an ICD (Zellner).
I feel that a physician is morally and ethically obligated to ensure their patient and their family is educated as to the function of the device, including how the device will act as the patient's health declines. I also feel that if a patient requests their device be deactivated, the physician either grants the request, or refers their patient to another physician who can. But when should a physician provide this education/counseling to patients and their family? At the time the device is inserted, or as the patient nears the end of their life? If you wait too long to provide support, are you telling the patient and their family that it's time to give up and there's no hope left?
Carroll, Linda. "Shocking Ending: Implanted Defibrillators can bring misery to final hours. http://vitals.msnbc.msn.com/news/2011/10/07/8212715-shocking-ending-implanted-defibrillators-can-bring-misery-to-final-hours
Zellner, Richard, Aulisio, Mark, and Lewis, William. "Should implanatable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated?". Circulation: Arrhythmia and Electrophysiology. 2009; 2: 340-344 Controversies in Arrhythmia and Electrophysiology. http://circep.ahajournals.org/content/2/3/340.full
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