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REPLY
Deactivating Implantable Cardioverter Defibrillators
Jeffrey T. Berger, MD
1 November 2005 | Volume 143 Issue 9 | Page 691
IN RESPONSE:
Ms. Ross argues that disabling a permanent pacemaker is active euthanasia because a pacemaker replaces natural cardiac physiology, because it is automatic and implanted, and because its action is not felt by the patient. These distinctions are not medically or ethically relevant to decisions regarding the appropriate continued use of pacemakers or to distinguishing active from passive euthanasia. Many treatments simply replace normal physiology (for example, insulin pumps, left ventricular assist devices, ventilators, renal replacement therapy through hemodialysis) and are automatic (ventilators, balloon pumps) or internalized (insulin pumps). Furthermore, for many neurologically impaired patients, life-sustaining treatments are "not felt by the patient," yet, contrary to Ms. Ross's criterion, these interventions are not typically considered to be "non-invasive." Continued use of pacemakers should not be accepted because they are already implanted and in use; rather, pacemakers are simply another medical intervention that can sustain life, the use of which should be based on whether the patient determines that its net effects are valuable.
I support Dr. Beattie, Mr. Ellershaw, and Mr. Connolly and Dr. Lynn in their call for greater attention to advance care planning with regard to ICDs, in addition to other life-sustaining technologies. Advance directives can assist families and physicians in implementing appropriate treatment plans and can remove legal obstacles to appropriate care. Unfortunately, several concerns remain with advance health planning, including widespread public reluctance to engage in this activity, culturally based discordance with advance directives, and other barriers that limit its influence in treatment (1-3). These challenges should not dissuade professionals from discussing treatment preferences with their patients. Rather, the health and legal systems should better integrate advance planning as well as family decision-making processes for patients who choose not to plan. Barriers to dialogue between physicians and patients should also be further examined (4, 5).
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Author and Article Information
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From Winthrop University Hospital, Mineola, NY 11501.
Potential Financial Conflicts of Interest: None disclosed.
1. Fagerlin A, Schneider CE. Enough. The failure of the living will. Hastings Cent Rep. 2004;34:30-42. [PMID: 15156835].[Medline]
2. Berger JT. Cultural discrimination in mechanisms for health decisions: a view from New York. J Clin Ethics. 1998;9:127-31. [PMID: 9750984].[Medline]
3. Teno JM, Stevens M, Spernak S, Lynn J. Role of written advance directives in decision making: insights from qualitative and quantitative data. J Gen Intern Med. 1998;13:439-46. [PMID: 9686709].[Medline]
4. Hofmann JC, Wenger NS, Davis RB, Teno J, Connors AF Jr, Desbiens N, et al. Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment. Ann Intern Med. 1997;127:1-12. [PMID: 9214246].[Abstract/Free Full Text]
5. Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. An empiric investigation of potential barriers. Arch Intern Med. 1994;154:2311-8. [PMID: 7944853].[Abstract]
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Academia and Clinic
The Ethics of Deactivating Implanted Cardioverter Defibrillators
Jeffrey T. Berger
- Annals 2005 142: 631-634.
[ABSTRACT][Full Text]
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