title: Ethical and legal views regarding deactivation of cardiac implantable electrical devices in patients with hypertrophic cardiomyopathy.
abstract: Little is known about patients' views surrounding the ethical and legal aspects of managing pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) near the end of life. Patients with hypertrophic cardiomyopathy (HC) are at heightened risk of sudden cardiac death and are common recipients of such devices. Patients with HC recruited from the membership of the Hypertrophic Cardiomyopathy Association were surveyed about their clinical histories, advance care planning, legal knowledge, and ethical beliefs relating to the withdrawal of PM and ICD therapy. The mean age of the 546 patients was 49.1 years, 47% were women, and 57% had ICDs. Only 46% of the respondents had completed an advance directive, only 51% had a healthcare proxy, and cardiac implantable electrical devices (CIEDs) were commonly not addressed in either (92% and 58%, respectively). Many patients characterized deactivating PMs or ICDs as euthanasia or physician-assisted suicide (29% for PMs and 17% for ICDs), and >50% expressed uncertainty regarding the legality of device deactivation. Patients viewed deactivation of ICDs and PMs as morally different from other life-sustaining therapies such as mechanical ventilation and dialysis, and these views varied substantially according to the CIED type (p <0.0001). The respondents expressed concerns regarding clinical conflicts related to religion, ethical and legal uncertainty, and informed consent. In conclusion, patients who have, or are eligible to receive, CIEDs might require improved advance care planning and education regarding the ethical and legal options for managing CIEDs at the end of life.
authors.affiliation: CardioVascular Institute, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, 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: Lisa
authors.initials: L
authors.lastname: Salberg
authors.forename: Dan W
authors.initials: DW
authors.lastname: Brock
authors.forename: William H
authors.initials: WH
authors.lastname: Maisel
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000941:ethics; D000368:Aged; D002312:Cardiomyopathy, Hypertrophic / Q000401:mortality / Q000628:therapy*; D016887:Cardiopulmonary Resuscitation / Q000941:ethics; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control; D017147:Defibrillators, Implantable / Q000941:ethics*; D004992:Ethics, Medical; D005260:Female; D006801:Humans; D007258:Informed Consent / Q000941:ethics / Q000331:legislation & jurisprudence; D007872:Legal Guardians; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000941:ethics*; D010358:Patient Participation / Q000331:legislation & jurisprudence; D012955:Societies, Medical; D013727:Terminal Care / Q000941:ethics* / Q000331:legislation & jurisprudence*; D028761:Withholding Treatment / Q000941:ethics* / Q000331:legislation & jurisprudence*