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Ethical Challenges of Deactivation of Cardiac Devices in Advanced Heart Failure

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Abstract

More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.

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Acknowledgments

This article was reviewed by Dr. Ayesha K. Hasan of the Ohio State University Wexner Medical Center.

Compliance with Ethics Guidelines

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Conflict of Interest

Hassan Chamsi-Pasha, Mohammed A. Chamsi-Pasha, and Mohammed Ali Albar declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Head of Non-Invasive Cardiology, Department of Cardiology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia

    Hassan Chamsi-Pasha

  2. Division of Cardiology, Department of Cardiovascular Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, NE, 68198-2265, USA

    Mohammed A. Chamsi-Pasha

  3. Department of Medical Ethics, International Medical Center, Jeddah, Saudi Arabia

    Mohammed Ali Albar

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  1. Hassan Chamsi-Pasha
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  2. Mohammed A. Chamsi-Pasha
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  3. Mohammed Ali Albar
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Correspondence to Mohammed A. Chamsi-Pasha.

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Chamsi-Pasha, H., Chamsi-Pasha, M.A. & Albar, M.A. Ethical Challenges of Deactivation of Cardiac Devices in Advanced Heart Failure. Curr Heart Fail Rep 11, 119–125 (2014). https://doi.org/10.1007/s11897-014-0194-8

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  • DOI: https://doi.org/10.1007/s11897-014-0194-8

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