Contextual Features
- From legal point of view the goal of treatment is changed to ensure comfortable end of life
- Deactivating ICD is not considered active killing: it is rather considered patient’s refusal of treatment
- A mentally competent patient has the right to refuse life saving treatment
- Hence patient has the right to request ICD deactivation
- ICD deactivation is similar to DNR
- Medical professionals should honor one’s refusal of treatment
- Patient doesn’t die from ICD turned off: patient dies from heart failure
- From patient’s perspective, patient’s autonomy to determine his/her own life should be respected
- Patient is morally allowed to reject because the burden outweighs the benefit and quality of life
- Actively dying patients can have tachyarrhythmia triggered by electrolyte imbalances and hypoxia
- Regardless of the cause, patients may still experience painful shocks
- Distresses family when patient receives shock from ICD at the end of life
- Families of patients who are actively dying want their loved ones to have a peaceful death
- However, there are still delays in deactivating devices, sometimes only minutes before death
- ICD is commonly overlooked by physician, patient, and family when advance directives are in place or created
nature of the ICD, and patients’ faith in the ICD’s life-restoring ability, it may be impossible for otherwise “healthy” patients to envision
a situation when they would want this life-saving technology withdrawn like they would for a hypothetical mechanical ventilator or
feeding tube” (Goldstein et al., 2007, p. 11).
- Patient and family education is not adequately given to encourage informed decision
- Delay is also caused because trained personnel or deactivating equipment is not readily available
- Some studies indicated that many physicians are uncomfortable with deactivating ICDs, even knowing of the discomfort the shocks cause
Provider issues that might influence treatment decisions:
- In October 2009, the treating physician stated the patient should not be resuscitated in the event of cardiac arrest
- Belief that resuscitation is futile
“Because an ICD can seem like a sentinel against death, a patient can develop ‘a complex psychological relationship’ with his device” (Russo, 2011).
- HOSPICE care physician or team observed that the existence of the defibrillator represented an “ethical dilemma.”
- Placing an ICD when patient was 90 years old with multiple co-morbidities and irreversible disease
- Family members. who were physicians themselves (one being a hospital administrator), were assisting with decision-making while aware of costs and likely outcome
- Patient had insurance but was it futile to place ICD?
- Patient’s wife philosophically believed that not trying everything would be an acceptance of death and similar to committing suicide
- Patients attitude and faith affects ICD deactivation
- Patients describe deactivation like committing suicide
- Suicide in religion is seen as a sin