Journal of Interventional Cardiac Electrophysiology

, Volume 32, Issue 3, pp 253–261

“I felt like the angel of death”: role conflicts and moral distress among allied professionals employed by the US cardiovascular implantable electronic device industry

  • Paul S. Mueller
  • Abigale L. Ottenberg
  • David L. Hayes
  • Barbara A. Koenig



This study aimed to identify themes associated with role conflicts and moral distress experienced by cardiovascular implantable electronic device (CIED) industry-employed allied professionals (IEAPs) in the clinical setting.


Focus groups were used to elicit perspectives from IEAPs who had deactivated a CIED.


Seventeen IEAPs (five women) reported increased clinical presence and work-related role conflicts and moral distress along several themes: (1) relationships with patients, (2) relationships with clinicians, (3) role ambiguity, (4) customer service to clinicians, and (5) CIED deactivation. Patients often misperceived IEAPs as physicians or nurses. Many physicians expected IEAPs to perform clinical duties. Customer service obligations exacerbated IEAP role conflicts and moral distress because of dual agency. IEAPs commonly received and carried out requests to deactivate CIEDs; doing so, however, generated considerable distress—particularly deactivations of pacemakers in pacemaker-dependent patients. Several described themselves as “angels of death.” IEAPs had recommendations for mitigating role conflicts and moral distress, including improving the deactivation process.


IEAPs experienced role conflicts and moral distress regarding their activities in the clinical setting and customer service obligations. Health care institutions should develop and enforce clear boundaries between IEAPs and clinicians in the clinical setting. Clinicians and IEAPs should adhere to these boundaries.


Device deactivation Device industry Ethics Industry-employed allied professional 



Cardiovascular implantable electronic device


Focus group


Heart Rhythm Society


Implantable cardioverter-defibrillator


Industry-employed allied professional


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Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Paul S. Mueller
    • 1
  • Abigale L. Ottenberg
    • 1
  • David L. Hayes
    • 2
  • Barbara A. Koenig
    • 1
    • 3
  1. 1.Division of General Internal MedicineMayo ClinicRochesterUSA
  2. 2.Division of Cardiovascular DiseasesMayo ClinicRochesterUSA
  3. 3.Division of Health Care Policy and ResearchMayo ClinicRochesterUSA

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