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Ethical Conundra in CIED Therapy: Ethical Implantation, Ethical End-of-Life Care

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Clinical Controversies in Device Therapy for Cardiac Arrhythmias

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Abstract

While defibrillators save lives in multiple populations, for those nearing the end of life, sudden death may not be an undesirable outcome. Ethical implantation of an ICD implies implanting only in those who otherwise have an expected longevity in the absence of lethal arrhythmia, of at least 2 years, with an acceptable quality of life. Shared decision-making around ICD implantation is critical for all patients. Two populations in whom particular care must be taken to ensure the benefits outweigh the risks, and are desired by the patient, are the elderly, and the demented. While age alone does not decrease ICD benefit, the presence of multiple comorbidities does. For those with dementia, particularly in the earlier stages, understanding the patient’s wishes for the long-term is crucial. For those with an ICD already implanted who are now nearing the end of their life, ICD shocks can bring pain without meaningful prolongation of life, and thus discussion of the option of deactivation of the shocking function is an ethical imperative. The ethical principal of autonomy demands that patients understand the options and the implications of those options. Legally, patients or their surrogates have a right to withdraw care that is no longer desired, even if it is life-sustaining.

Relationships with industry: Dr Lampert has received significant research funding from Boston Scientific, Medtronic, and Abbott/St Jude Medical (significant),and has received honoraria and consulting fees from Medtronic (modest).

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  1. Yale University School of Medicine, New Haven, CT, USA

    Rachel Lampert

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  1. Rachel Lampert
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Correspondence to Rachel Lampert .

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  1. University of Rochester School of Medicine & Dentistry/Hackensack Meridian, School of Medicine at Seton Hall, University/Summit Medical Group, Short Hills, NJ, USA

    Jonathan S. Steinberg

  2. Electrophysiology Section, Cardiovascular Division, Univeristy of Pennsylvania, and the Cardiology Division, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA

    Andrew E. Epstein

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Lampert, R. (2019). Ethical Conundra in CIED Therapy: Ethical Implantation, Ethical End-of-Life Care. In: Steinberg, J., Epstein, A. (eds) Clinical Controversies in Device Therapy for Cardiac Arrhythmias . Springer, Cham. https://doi.org/10.1007/978-3-030-22882-8_10

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