Journal of Interventional Cardiac Electrophysiology

, Volume 32, Issue 3, pp 243–252

“Just Because We Can Doesn’t Mean We Should”: views of nurses on deactivation of pacemakers and implantable cardioverter-defibrillators

  • Daniel B. Kramer
  • Abigale L. Ottenberg
  • Samantha Gerhardson
  • Luke A. Mueller
  • Sharon R. Kaufman
  • Barbara A. Koenig
  • Paul S. Mueller
Article

Abstract

Purpose

This study aims to identify nurses’ concerns about the clinical, ethical, and legal aspects of deactivating cardiovascular implantable electronic devices (CIEDs).

Methods

We used focus groups to discuss decision making in CIED management.

Results

Fourteen nurses described the informed consent process as overly focused on procedures, with inadequate coverage of living with a device (e.g., infection risks and device shocks). Elderly patients were especially vulnerable to physician or family pressure about CIED implantation. Nurses believed that initial advance care planning discussions were infrequent and rarely revisited when health status changed. Many patients did not know that CIEDs could be deactivated; it was often addressed reactively (i.e., after multiple shocks) or when patients became too ill to participate in decision making. Nurses generally were supportive of CIED deactivation when it was requested by a well-informed patient. However, nurses distinguished between withholding versus withdrawing treatment (i.e., turning off CIEDs vs. declining implantation). Although most patients viewed their device as lifesaving, others perceived them as a “ticking time bomb.”

Conclusions

Nurses identified concerns about CIED decision making from implantation through end-of-life care and device deactivation and suggested avenues for improving patient care including early and regular advance care planning.

Keywords

Device deactivation Ethics Implantable cardioverter-defibrillators Nursing Pacemakers 

Abbreviations

CIED

Cardiovascular implantable electronic device

ICD

Implantable cardioverter-defibrillator

References

  1. 1.
    Epstein, A. E., DiMarco, J. P., Ellenbogen, K. A., Estes, N. A. 3rd., Freedman, R. A., Gettes, L. S., et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices); American Association for Thoracic Surgery; Society of Thoracic Surgeons. (2008) ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation, 117(21):e350–408. Epub 2008 May 15. Erratum in: Circulation, 2009 120(5):e34–5Google Scholar
  2. 2.
    Mond, H. G., Irwin, M., Ector, H., & Proclemer, A. (2008). The world survey of cardiac pacing and cardioverter-defibrillators: calendar year 2005 an International Cardiac Pacing and Electrophysiology Society (ICPES) project. Pacing and Clinical Electrophysiology, 31(9), 1202–1212.PubMedCrossRefGoogle Scholar
  3. 3.
    Mueller, P. S., Hook, C. C., & Hayes, D. L. (2003). Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clinic Proceedings, 78(8), 959–963.PubMedCrossRefGoogle Scholar
  4. 4.
    Lampert, R., Hayes, D. L., Annas, G. J., Farley, M. A., Goldstein, N. E., Hamilton, R. M., et al; American College of Cardiology; American Geriatrics Society; American Academy of Hospice and Palliative Medicine, American Heart Association; Hospice and Palliative Nurses Association. (2010). HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm, 7(7), 1008–1026.Google Scholar
  5. 5.
    Mueller, P. S., Jenkins, S. M., Bramstedt, K. A., & Hayes, D. L. (2008). Deactivating implanted cardiac devices in terminally ill patients: practices and attitudes. Pacing and Clinical Electrophysiology, 31(5), 560–568.PubMedCrossRefGoogle Scholar
  6. 6.
    Kramer, D. B., Kesselheim, A. S., Brock, D. W., & Maisel, W. H. (2010). Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment. Heart Rhythm, 7(11), 1537–1542. Epub 2010 Jul 19.PubMedCrossRefGoogle Scholar
  7. 7.
    Goldstein, N. E., Mehta, D., Siddiqui, S., Teitelbaum, E., Zeidman, J., Singson, M., et al. (2008). “That’s like an act of suicide” patients’ attitudes toward deactivation of implantable defibrillators. Journal of General Internal Medicine, 23(Suppl 1), 7–12.PubMedCrossRefGoogle Scholar
  8. 8.
    Goldstein, N. E., Mehta, D., Teitelbaum, E., Bradley, E. H., & Morrison, R. S. (2008). “It’s like crossing a bridge” complexities preventing physicians from discussing deactivation of implantable defibrillators at the end of life. Journal of General Internal Medicine, 23(Suppl 1), 2–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Kelley, A. S., Reid, M. C., Miller, D. H., Fins, J. J., & Lachs, M. S. (2009). Implantable cardioverter-defibrillator deactivation at the end of life: a physician survey. American Heart Journal, 157(4), 702–8.e1. Epub 2009 Feb 23.PubMedCrossRefGoogle Scholar
  10. 10.
    Schmidlin, E. (2008). Artificial hydration: the role of the nurse in addressing patient and family needs. International Journal of Palliative Nursing, 14(10), 485–489.PubMedGoogle Scholar
  11. 11.
    Kirchhoff, K. T., Spuhler, V., Walker, L., Hutton, A., Cole, B. V., & Clemmer, T. (2000). Intensive care nurses’ experiences with end-of-life care. American Journal of Critical Care, 9(1), 36–42.PubMedGoogle Scholar
  12. 12.
    Shotton, L. (2000). Can nurses contribute to better end-of-life care? Nursing Ethics, 7(2), 134–140.PubMedGoogle Scholar
  13. 13.
    Thacker, K. S. (2008). Nurses’ advocacy behaviors in end-of-life nursing care. Nursing Ethics, 15(2), 174–185.PubMedCrossRefGoogle Scholar
  14. 14.
    Denzin, N. K., & Lincoln, Y. S., editors. The SAGE handbook of qualitative research. 3rd ed. Thousand Oaks, CA: SAGE Publications. c2005.Google Scholar
  15. 15.
    Krueger, R. A., & Casey, M. A., editors. Focus groups: a practical guide for applied research. 4th ed. Los Angeles, CA: SAGE; c2009. p. 4–6.Google Scholar
  16. 16.
    Clarke, A. E. Situational analysis: grounded theory after the postmodern turn. Thousand Oaks, CA: SAGE; c2005.Google Scholar
  17. 17.
    Strauss, A. L. Qualitative analysis for social scientists. Cambridge, NY: Cambridge University Press; c1987.Google Scholar
  18. 18.
    Pope, C., Ziebland, S., & Mays, N. (2000). Qualitative research in health care: analyzing qualitative data. BMJ, 320(7227), 114–116.PubMedCrossRefGoogle Scholar
  19. 19.
    Al-Khatib, S. M., Hellkamp, A., Curtis, J., Mark, D., Peterson, E., Sanders, G. D., et al. (2011). Non-evidence-based ICD implantations in the United States. JAMA., 305(1), 43–49.PubMedCrossRefGoogle Scholar
  20. 20.
    Sherazi, S., Daubert, J. P., Block, R. C., Jeevanantham, V., Abdel-Gadir, K., DiSalle, M. R., et al. (2008). Physicians’ preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator. Mayo Clinic Proceedings, 83(10), 1139–1141.PubMedCrossRefGoogle Scholar
  21. 21.
    Padeletti, L., Arnar, D. O., Boncinelli, L., Brachman, J., Camm, J. A., Daubert, J. C., et al. (2010). EHRA expert consensus statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy. Europace, 12(10), 1480–1489. Epub 2010 Jul 30.PubMedCrossRefGoogle Scholar
  22. 22.
    Mueller, P. S., Swetz, K. M., Freeman, M. R., Carter, K. A., Crowley, M. E., Severson, C. J., et al. (2010). Ethical analysis of withdrawing ventricular assist device support. Mayo Clinic Proceedings, 85(9), 791–797. Epub 2010 Jun 28.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Daniel B. Kramer
    • 1
  • Abigale L. Ottenberg
    • 2
    • 3
  • Samantha Gerhardson
    • 5
  • Luke A. Mueller
    • 5
  • Sharon R. Kaufman
    • 6
  • Barbara A. Koenig
    • 2
    • 4
  • Paul S. Mueller
    • 2
    • 3
  1. 1.Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Division of General Internal MedicineMayo ClinicRochesterUSA
  3. 3.Program for Professionalism and EthicsMayo ClinicRochesterUSA
  4. 4.Division of Health Care Policy and ResearchMayo ClinicRochesterUSA
  5. 5.Augsburg CollegeMinneapolisUSA
  6. 6.Institute for Health and Aging, School of NursingUniversity of California, San FranciscoSan FranciscoUSA

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