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Question

Difficulty: MediumEnd-of-Life and Palliative Care

A 72-year-old man with end-stage heart failure secondary to ischemic cardiomyopathy is admitted to the inpatient hospice unit. He has an implantable cardioverter-defibrillator (ICD) that also provides biventricular pacing. Over the past week, his condition has deteriorated significantly; he is now bedbound and requires continuous intravenous morphine for severe resting dyspnea. He remains fully alert, oriented, and capable of communicating his wishes. Today, he experienced three painful ICD shocks for episodes of ventricular tachycardia. He tells the attending physician, "These shocks are agonizing. Please turn this machine off so I can pass peacefully." The patient's wife expresses deep distress and states, "I want him to be comfortable, but isn't turning off his heart device the same as physician-assisted suicide? Can't we just give him medication for the rhythm instead?" Which of the following is the most appropriate next step in management?

  1. Deactivate the defibrillation function of the ICD while maintaining the pacing functionAnswer
  2. B
    Deactivate both the defibrillation and biventricular pacing functions of the ICD
  3. C
    Initiate an intravenous amiodarone infusion to suppress the ventricular arrhythmias
  4. D
    Initiate continuous palliative sedation with midazolam to induce unconsciousness
  5. E
    Consult the hospital ethics committee to resolve the conflict with the patient's wife

Answer

Deactivate the defibrillation function of the ICD while maintaining the pacing function.
The patient has decision-making capacity and has requested the withdrawal of a life-sustaining treatment that is causing him pain. Ethically and legally, deactivating an ICD is considered withdrawal of medical therapy, not physician-assisted suicide or euthanasia. The most appropriate clinical approach is to deactivate the defibrillation (shock) function to eliminate the agonizing shocks, while leaving the biventricular pacing function active. The pacing function helps maintain cardiac output and synchrony, and turning it off could precipitate acute hemodynamic deterioration and worsen his dyspnea, which contradicts the primary goal of comfort care.

Step-by-Step Solution

1
Assess the patient's decision-making capacity.
The patient is fully alert, oriented, and clearly communicating his wishes, confirming he has the capacity to make medical decisions.
Capacity is the foundation for respecting patient autonomy in end-of-life care.
2
Evaluate the ethical implications of withdrawing the device.
Deactivating an ICD is legally and ethically considered the withdrawal of life-sustaining treatment, which is permissible and distinct from physician-assisted suicide.
Understanding the ethical distinction is necessary to counsel the distressed family and comply with the patient's request.
3
Determine the optimal technical management of the ICD.
The defibrillation (shock) function should be turned off to prevent pain, but the biventricular pacing function should be left on to maintain cardiac synchrony and prevent acute symptom worsening.
In palliative care, interventions that provide symptom relief (like pacing) are maintained, while those that cause distress (like shocks) are discontinued.

Key Concept

Management of Implantable Cardioverter-Defibrillators (ICDs) and ethical withdrawal of life-sustaining therapy at the end of life.
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Topics

End-of-Life and Palliative Care

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