36201 - Ethical aspects of deactivating implanted cardiac...

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Ethical aspects of deactivating implanted cardiac devices Paul S. Mueller, MD, MPH, FACP Associate Professor of Medicine
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Disclosures I am a member of the Boston Scientific Patient Safety Advisory Board I am an associate editor for Journal Watch No off-label use of drugs or devices will be discussed
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Objectives Describe the permissibility of withholding and withdrawing life-sustaining treatments (W/W LSTs) Differentiate W/W LSTs from physician- assisted suicide and euthanasia Describe the results of research related to the ethical aspects of withholding device therapy and deactivating implanted cardiac devices
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Cases and questions to ponder
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Case 1 Refusal 72-year-old man presents with syncope; he is found to have intermittent complete heart block Pacemaker (PM) therapy is recommended He declines He understands the risks and benefits of, and the alternatives to, his decision How do you respond?
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Case 1 1. Refer the patient to a psychiatrist since his decision is irrational 2. Have your institutional ethics committee review and approve his decision 3. Ensure that his decision is informed and if so, respect it 4. Ask one of his loved ones to convince him that his decision is wrong 5. Force him to undergo PM implantation
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Case 2 Request for withdrawal 72-year-old man with CHF and ventricular dysrhythmias undergoes ICD implantation Despite medication adjustments, he is shocked 3 times the week after device implantation He now demands ICD deactivation He understands the implications of his request How do you respond to his request?
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Case 2 1. Refer the patient to a psychiatrist since his request is irrational 2. Obtain an ethics consultation 3. Ensure that his request is informed and if so, deactivate the ICD 4. Ask a chaplain to convince him that his request is wrong 5. Refuse to comply as his request is akin to euthanasia
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Case 3 Request for withdrawal 72-year-old man dying of lung cancer He has a PM for complete heart block with unstable escape Fearing the PM will prolong the dying process, he requests PM deactivation He understands the implications of PM deactivation How do you respond to his request?
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Case 3 1. Refer the patient to a psychiatrist since his request is irrational 2. Comply if the hospital attorney agrees 3. Ensure that his request is informed and if so, deactivate the PM 4. Ask his family to convince him that his request is wrong 5. Refuse to comply as granting his request is akin to euthanasia
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Case 4 Request for withdrawal 72-year-old man with CHF has an ICD for ventricular dysrhythmias Now hospitalized with cancer and sepsis, he is delirious and dying There is no advance directive Fearing shocks during the dying process and citing the patient’s values and goals, his family requests ICD deactivation They understand the implications of ICD deactivation How do you respond?
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Question 4 1. Refuse to comply since there is no advance directive 2. Obtain an ethics consultation 3. Call the hospital attorney for advice 4. Deactivate the ICD 5. Refuse to comply as granting the request is akin to euthanasia
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This note was uploaded on 02/26/2012 for the course PHARM 210 taught by Professor Staff during the Fall '10 term at Rutgers.

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36201 - Ethical aspects of deactivating implanted cardiac...

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