Baylor University Medical Center Proceedings April 2017 - 158


These comorbidities also help predict potential arrhythmias as the
terminal illness progresses. Thus, all
pertinent medical records should
be obtained and queried for such
documentation. Communication
between the health care providers themselves, and then between
the health care providers and the
patient and his or her surrogate(s)
or family, is essential to provide
information and set expectations.
Concise documentation of these
communications and detailed consent forms are very important from
a legal standpoint (4).

a

b

ETHICAL CONSIDERATIONS
Pacemaker-dependent patients
may request deactivation of their
device towards the end of life.
Ethical analyses of withdrawal of
CIEDs have compared them to
other life-sustaining treatments
that physicians readily withdraw
near the end of life, such as hemodialysis or mechanical ventilators.
c
Physicians are often concerned that
deactivation of pacemaker function towards the end of life could
be interpreted as assisted dying,
analogous to voluntary euthanasia. Most medical ethicists agree
that when death follows withdrawal of treatment, the person's
underlying condition is deemed
the actual cause of death (4). It is
unethical, on the other hand, to
"withdraw or discontinue" a treatment that becomes a part of the
Figure 1. Anteroposterior and lateral views showing the appearance of different device leads on chest x-ray. patient's "self," like a heart trans(a) Pacemaker leads in the right atrium (RA) and right ventricle (RV). Some patients have a biventricular device, plant. Most ethicists, though, do
which would have a similar pacing lead in the coronary sinus. (b) A defibrillator lead in the right ventricle (RV). Notice not consider a pacemaker a part of
the thickness of the lead due to the defibrillation coil. (c) A subcutaneous defibrillator.
the patient's self and thus it can be
withdrawn, like a ventilator (5).
thick coil indicates that the device is an ICD. Every ICD lead
Such withdrawal is lawful, provided that it follows from the
also has built-in pacemaker functionality, even if pacing was not
person's competent refusal of treatment. Currently in the US,
indicated. Diﬀerent companies and models have distinct shapes
ethically and legally, there are no diﬀerences between refusing
on an x-ray (2, 3). If the device cannot be identiﬁed radiologiCIED therapy and requesting withdrawal of CIED therapy.
cally, diﬀerent company devices can be applied to identify the
Laws governing the management of CIEDs towards the end of
device make and model, as a last resort.
life vary by country, and physicians should acquaint themselves
The patient's medical condition needs to be studied thorwith the rules of their jurisdiction (5-7).
oughly to identify the cardiac condition that led to the device
Although patients have the right to request withdrawal of
implantation, including a history of any arrhythmias or device
therapy, it is possible that the personal and professional values
therapies or other medical conditions. Often, noncardiac coof the care provider and the patient may diﬀer. Heart Rhythm
morbidities are more pertinent to a patient's life expectancy.
Society guidelines (1) stipulate that clinicians in this position
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Baylor University Medical Center Proceedings

Volume 30, Number 2
Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings April 2017
