title: Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment.
abstract: BACKGROUND
  Despite the high prevalence of pacemakers and implantable cardioverter-defibrillators, little is known about physicians' views surrounding the ethical and legal aspects of managing these devices at the end of life.
  
  
  OBJECTIVE
  The purpose of this study was to identify physicians' experiences and views surrounding the ethical and legal aspects of managing cardiac devices at the end of life.
  
  
  METHODS
  Survey questions were administered to internal medicine physicians and subspecialists at a tertiary care center. Physicians were surveyed about their clinical experience, legal knowledge, and ethical beliefs relating to the withdrawal of PM and ICD therapy in comparison to other life-sustaining therapies.
  
  
  RESULTS
  Responses were obtained from 185 physicians. 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%, P <.0001), dialysis (60.6% vs 33.9%, P <.001), and feeding tubes (73.8% vs 33.9%, P <.0001). Physicians were consistently less comfortable discussing cessation of PMs and ICDs compared to other life-sustaining therapies (P <.005). Only 65% of physicians correctly identified the legal status of euthanasia in the United States, and 20% accurately reported the legal status of physician-assisted suicide in the United States. 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%, P = .027) or euthanasia (9% vs 1%, P <.001).
  
  
  CONCLUSIONS
  In this single-center study, internists were less comfortable discussing cessation of PM and ICD therapy compared to other life-sustaining therapies and lacked experience with this practice. Education regarding the legal and ethical parameters of device deactivation is needed.
authors.affiliation: CardioVascular Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02446, USA. dkramer@bidmc.harvard.edu
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Kramer
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Kesselheim
authors.forename: Dan W
authors.initials: DW
authors.lastname: Brock
authors.forename: William H
authors.initials: WH
authors.lastname: Maisel
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003657:Decision Making; D017147:Defibrillators, Implantable / Q000941:ethics*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000941:ethics*; D010819:Physician's Role; D013727:Terminal Care; D028761:Withholding Treatment; D055815:Young Adult