When treatment options dwindle or are exhausted, terminally ill-patients often opt for pain management and comfort over life-extending therapies.
However, a team of researchers from Wake Forest University Baptist Medical Center, University of Rochester Medical Center and Unity Health System, report that a lack of thorough understanding about the laws governing end-of-life care may be leaving many medical providers with an ethical dilemma and causing some terminally-ill patients considerable, unnecessary pain.
The report, appearing in a recent issue of Mayo Clinic Proceedings, concerns the legal and ethical issues involved with deactivating an implantable cardioverter-defibrillator (ICD) in patients who are terminally-ill. The ICD is a small, battery-powered electrical impulse generator, much like a pacemaker, that is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation. The device is programmed to detect cardiac arrhythmia and correct it by delivering a jolt of electricity, which is often lifesaving. However, the legality of deactivating the ICD in terminally-ill patients who request to stop receiving the therapy is not clearly written, the study shows, and may be causing doctors to subject dying patients to undue pain.
The results stem from a physician survey that collected information about doctors' knowledge and preferences regarding the medical, ethical and legal issues involved in caring for terminally-ill patients with an ICD.
In the brief, Vinodh Jeevanantham, M.D., of Wake Forest Baptist, and colleagues identify a general lack of knowledge among physicians concerning ICD therapy in terminally-ill patients that may result in extra suffering for them.
The ICD has become the most effective treatment for patients at high risk of life-threatening ventricular arrhythmias. It has been shown to improve survival, especially in elderly patients, by sensing changes in cardiac rhythm and delivering an electrical shock to the heart to restore normal rhythm.
Terminally-ill patients may be at increased risk of ICD shocks due to electrolyte disturbances, hypoxia and heart failure. It is estimated that more than 3 million people in North America are now eligible for an ICD. With a growing elderly population in the United States, clinicians are likely to care for an increasing number of elderly patients with ICDs.
The deactivation of an ICD, which may have been placed years before the onset of a terminal condition, may not be a clear-cut decision for patients, families, or physicians. Although physicians are aware that ICDs save lives by delivering an electrical shock and that such shocks are associated with considerable pain, busy clinicians may not always re-analyze the risk-benefit ratio of ICD therapy when their patient experiences a terminal illness, the report states. In this situation, life-prolonging therapy may no longer be desired. However, although guidelines for appropriate ICD use are readily available, a glaring deficiency exists regarding end-of-life care for patients with an ICD, according to the report, and the legality of deactivation is not clearly spelled out. There are also no clear-cut recommendations, Jeevanantham said.
Although voluntary refusal of treatment is a basic patient right, the study highlights a lack of clarity regarding the laws concerning ICD therapy in terminally-ill patients.