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Deactivating Implantable Cardioverter Defibrillators
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
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•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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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).
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
Article and Author Information
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Potential Financial Conflicts of Interest: None disclosed.
