Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: results of a survey of medical and legal professionals and patients

Abstract

Objective: To determine the opinions of medical professionals, legal professionals, and patients regarding the withdrawal of implantable cardioverter-defibrillator (ICD) and pacemaker therapy at the end of life.

Participants and methods: A survey regarding 5 cases that focused on withdrawal of ICD or pacemaker therapy at the end of life was constructed and sent to 5270 medical professionals, legal professionals, and patients. The survey was administered from March 1, 2008, to March 1, 2009.

Results: Of the 5270 recipients of the survey, 658 (12%) responded. In a terminally ill patient requesting that his ICD be turned off, most legal professionals (90% [63/70]), medical professionals (98% [330/336]), and patients (85% [200/236]) agreed the ICD should be turned off. Most legal professionals (89%), medical professionals (87%), and patients (79%) also considered withdrawal of pacemaker therapy in a non-pacemaker-dependent patient appropriate. However, significantly more legal (81%) than medical professionals (58%; P<.001) or patients (68%, P=.02) agreed with turning off a pacemaker in the pacemaker-dependent patient. A similar number of legal professionals thought turning off a device was legal regardless of whether it was an ICD or pacemaker (45% vs 38%; P=.50). However, medical professionals were more likely to perceive turning off an ICD as legal than turning off a pacemaker (85% vs 41%; P<.001).

Conclusion: Most respondents thought device therapy should be withdrawn if the patient requested its withdrawal at the end of life. However, opinions of medical professionals and patients tended to be dependent on the type of device, with turning off ICDs being perceived as more acceptable than turning off pacemakers, whereas legal professionals tended to perceive all devices as similar. Thus, education and discussion regarding managing devices at the end of life are important when having end-of-life discussions and making end-of-life decisions to better understand patients' perceptions and expectations.

FIGURE 1.

Perceptions of the legality of withdrawing implantable cardioverter-defibrillator (ICD) therapy. Shown is the percentage of medical professionals, legal professionals, and patients who perceived withdrawal of ICD therapy as legal, of unclear legal status, or as akin to physician-assisted suicide or euthanasia or who offered no opinion. All groupwise comparisons were significant (P<.001), except for the comparison between legal professionals and patients, with a similar percentage believing that withdrawal of ICD therapy was akin to physician-assisted suicide or euthanasia. The actual percentage for each group is listed above the respective bar.

FIGURE 2.

Perceptions of the legality of withdrawing pacemaker (PM) therapy. Shown is the percentage of medical professionals, legal professionals, and patients who perceived withdrawal of PM therapy in a completely PM-dependent patient as legal, of unclear legal status, or as akin to physician-assisted suicide or euthanasia or who offered no opinion. More medical professionals perceived withdrawal of therapy as akin to physician-assisted suicide or euthanasia than legal professionals or patients (P<.001). In contrast, more legal professionals perceived the legal status as unclear than medical professionals or patients (P<.001). The percentage of respondents who perceived withdrawal as legal did not differ significantly among the groups. The actual percentage for each group is listed above the respective bar.

FIGURE 3.

Perceptions regarding pacemaker (PM) withdrawal at the end of life: akin to physician-assisted suicide or euthanasia? Shown is the percentage of medical professionals, legal professionals, and patients who perceived withdrawal of PM therapy as akin to physician-assisted suicide or euthanasia in a PM-dependent vs non–PM-dependent patient. Significantly more medical professionals and patients thought that PM withdrawal was akin to physician-assisted suicide or euthanasia when patients were PM-dependent than when they were not (P<.001). The actual percentage for each group is listed above the respective bar.

FIGURE 4.

Perceptions of whether pacemaker (PM) therapy should be withdrawn at the end of life on the basis of a patient's right to refuse. Shown is the percentage of medical professionals, legal professionals, and patients who thought that PM therapy should be withdrawn on the basis of the patient's right to refuse further therapy in a PM-dependent vs non–PM-dependent patient. Although most medical professionals, legal professionals, and patients thought that therapy should be withdrawn in either group, significantly fewer medical professionals and patients thought that PM withdrawal was appropriate when the patient was PM-dependent than when they were not (P<.001). However, the perception of legal professionals did not differ significantly with regard to device dependence. The actual percentage for each group is listed above the respective bar.

FIGURE 5.

Comparison of the perceptions of legality of turning off implantable cardioverter-defibrillator (ICD) vs pacemaker (PM) therapy. Shown is the percentage of medical professionals, legal professionals, and patients who perceived withdrawing ICD vs PM therapy (when the patient was PM-dependent) as either legal or as akin to physician-assisted suicide or euthanasia. Significantly more medical professionals and patients perceived withdrawal of ICD therapy as legal (P<.001); however, the opinions of legal professionals did not differ significantly on the basis of device type. However, all groups (medical professionals [P<.001], legal professionals [P<.01] and patients [P<.001]) were more likely to perceive withdrawing PM therapy as akin to physician-assisted suicide or euthanasia than withdrawing ICD therapy. The actual percentage for each group is listed above the respective bar.