Doctors' legal questions might result in patient pain
When treatment options dwindle or are exhausted, terminally ill patients often opt for pain management and comfort over life-extending therapies. However, researchers report that a lack of thorough understanding about the laws governing end-of-life care might leave providers with an ethical dilemma and cause some terminally ill patients considerable, unnecessary pain.
The report, appearing in a recent issue of Mayo Clinic Proceedings, concerns the legal and ethical issues involved with deactivating an implantable cardioverter-defibrillator (ICD) in patients who are terminally ill. The researchers were from University of Rochester Medical Center and Unity Health System, both in Rochester, NY, and Wake Forest University Baptist Medical Center in Winston-Salem, NC.
The legality of deactivating the ICD in terminally ill patients who request to stop receiving the therapy is not clearly written, the study shows, and might be causing doctors to subject dying patients to undue pain.
The results stem from a physician survey that collected information about doctors' knowledge and preferences regarding the medical, ethical, and legal issues involved in caring for terminally ill patients with an ICD. Vinodh Jeevanantham, MD, of Wake Forest Baptist, and colleagues identify a general lack of knowledge among physicians concerning ICD therapy in terminally ill patients that might result in extra suffering.
Terminally ill patients might be at increased risk of ICD shocks due to electrolyte disturbances, hypoxia, and heart failure. It is estimated that more than 3 million people in North America are eligible for an ICD. With a growing elderly population in the United States, clinicians are likely to care for an increasing number of elderly patients with ICDs.
The deactivation of an ICD, which might have been placed years before the onset of a terminal condition, might not be a clear-cut decision for patients, families, or physicians. Although physicians are aware that ICDs save lives by delivering an electrical shock and that such shocks are associated with considerable pain, busy clinicians might not always reanalyze the risk-benefit ratio of ICD therapy when their patient experiences a terminal illness, the report states. In this situation, life-prolonging therapy might no longer be desired. Although guidelines for appropriate ICD use are readily available, a glaring deficiency exists regarding end-of-life care for patients with an ICD, according to the report.
Although voluntary refusal of treatment is a basic patient right, the study highlights a lack of clarity regarding the laws concerning ICD therapy in terminally ill patients. "While 64 of the physicians who participated in our survey had cared for terminally ill patients with an ICD, they were unaware of any guidelines regarding deactivation of the device in such patients," the authors wrote.
Although patients can better tolerate the shock from the ICD with time, they still might find an ICD firing frightening and painful, the researchers said. "Our study showed that only 51 clinicians thought that the shock therapy would be uncomfortable," they said. This finding highlights the importance of physician education regarding the ICD functioning, particularly regarding symptoms that result from shock therapy.
"With increased knowledge about managing the withdrawal of this potentially life-prolonging therapy, physicians are likely to become more skilled at caring for dying patients with an ICD," the authors said.
When treatment options dwindle or are exhausted, terminally ill patients often opt for pain management and comfort over life-extending therapies.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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