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Difficulty: MediumEnd-of-Life and Palliative Care

A 76-year-old man with end-stage ischemic cardiomyopathy (left ventricular ejection fraction of 15%) is admitted to the hospital with cardiogenic shock. He has an implantable cardioverter-defibrillator (ICD) that was placed 4 years ago for secondary prevention of sudden cardiac death. Despite continuous milrinone infusion, he remains hypotensive, oliguric, and dyspneic at rest. After extensive discussions with the palliative care team, the patient expresses a clear desire to transition to comfort measures only and wants to be discharged home with hospice services. He specifically requests that his ICD be deactivated, as he has received three painful shocks in the last week and fears experiencing more shocks as he dies. The patient's son, who is the legally designated healthcare proxy, is very upset and states, 'You cannot turn off his defibrillator, that is like killing him!' The patient is fully alert, oriented, and clearly demonstrates an understanding of his prognosis and the consequences of deactivating the device. Which of the following is the most appropriate next step in management?

  1. Deactivate the defibrillator function of the ICD prior to hospital dischargeAnswer
  2. B
    Follow the son's directive to keep the ICD active, as he is the legally designated healthcare proxy
  3. C
    Request a psychiatric consultation to establish the patient's legal competence to refuse life-sustaining treatment
  4. D
    Discharge the patient to home hospice immediately and instruct the hospice agency to coordinate ICD deactivation
  5. E
    Maintain ICD function and prescribe high-dose scheduled opiates to mitigate the pain of subsequent shocks

Answer

Deactivate the defibrillator function of the ICD prior to hospital discharge.
The correct action is to deactivate the defibrillator function of the ICD prior to hospital discharge. In end-of-life care, deactivating an ICD is considered equivalent to withholding or withdrawing any other life-sustaining therapy (like mechanical ventilation or hemodialysis). Because the patient has intact decision-making capacity (evidenced by his ability to understand his prognosis and the consequences of his choice), his autonomous decision supersedes the objections of his son. The healthcare proxy's authority is only activated if the patient loses capacity. The deactivation should occur before discharge to ensure the patient does not suffer painful, unwanted shocks during transport or at home.

Step-by-Step Solution

1
Assess the patient's clinical decision-making capacity.
The patient is alert, oriented, and understands his prognosis and the consequences of his choice, meaning he possesses intact decision-making capacity.
Capacity is the prerequisite for a patient to autonomously make healthcare decisions, including the refusal of life-sustaining treatment.
2
Evaluate the role of the surrogate decision-maker (the son).
The son's objections do not override the patient's decision.
A designated healthcare proxy or surrogate decision-maker only has authority when the primary patient loses clinical capacity.
3
Determine the ethical permissibility of ICD deactivation.
Deactivating an ICD is ethically and legally equivalent to withdrawing any other life-sustaining medical treatment, not euthanasia or physician-assisted suicide.
Patients have the right to refuse any medical intervention. Continuing shocks would cause unnecessary pain, violating the principle of nonmaleficence and the patient's goal of comfort.
4
Determine the appropriate timing for deactivation.
The device must be deactivated prior to discharge.
Sending the patient home with an active ICD exposes him to painful shocks during transport and while awaiting hospice intake, which constitutes poor symptom management.

Key Concept

ICD Deactivation in End-of-Life Care and Patient Autonomy
Estimated Time:1m 15s
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Topics

End-of-Life and Palliative Care

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