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An ethics consultation case is presented in which a hospice patient wished to deactivate his Cardiovascular Implantable Electronic Device (CIED), specifically an implantable cardioverter-defibrillator, at the end of life to prevent the prolongation of the dying. The consultants developed an ethical analysis supporting the deactivation of the pacemaker based on authoritative literature and moral reasoning. The consultants’ recommendations to deactivate the pacemaker were ultimately rejected by the medical team based on an alternative assessment which concluded the patient is suicidal, doubts based on the consultants not being physicians, and the healthcare professionals’ sense that deactivating a pacemaker is different from withdrawing other forms of life-sustaining treatment at the end of life. Professional reflections by the consultants and lessons learned are discussed.
Edited by
Dharti Patel, Mount Sinai West and Morningside Hospitals, New York,Sang J. Kim, Hospital for Special Surgery, New York,Himani V. Bhatt, Mount Sinai West and Morningside Hospitals, New York,Alopi M. Patel, Rutgers Robert Wood Johnson Medical School, New Jersey
A defibrillator is a device designed to treat ventricular arrhythmias by delivery of an electrical shock that terminates the arrhythmia and restores a normal cardiac rhythm. Defibrillators can be external or internal/implanted (ICD). This chapter reviews the types of defibrillators, with a particular focus on the perioperative management of ICDs. Indications, pad and lead placement, shock therapy, and identification of ICDs are covered.
Expert guidance from scientific societies and regulatory agencies recommend a framework of principles for frequency of in-person evaluations and remote monitoring for patients with cardiac implantable electronic devices. However, there are limited data regarding adherence to recommendations among paediatric electrophysiologists, and there are no data regarding cardiac implantable electronic device-related ancillary testing.
Methods:
To assess current clinical practices for cardiac implantable electronic device in-person evaluation, remote monitoring, and cardiac implantable electronic device-related ancillary testing, the Paediatric and Congenital Electrophysiology Society members were surveyed. The main outcome measures were variations in frequency of in person evaluation, frequency of remote monitoring, and cardiac implantable electronic device-related ancillary testing.
Results:
All respondents performed in-person evaluation at least once a year, but <50% of respondents performed an in-person evaluation within 2 weeks of cardiac implantable electronic device implantation. Remote monitoring was performed every 3 months for pacemakers and implantable cardioverter defibrillators by 71 and 75% respondents, respectively. Follow-up echocardiography was performed every 2–3 years by 53% respondents for patients with >50% ventricular pacing. Majority of respondents (75%) did not perform either an exercise stress test or ambulatory Holter monitoring or chest X-ray (65%) after cardiac implantable electronic device implantation.
Conclusion:
This survey identified significant practice variations in cardiac implantable electronic device in- person evaluation, remote monitoring, and ancillary testing practices among paediatric electrophysiologists. Cardiac implantable electronic device management may be optimised by development of a paediatric-specific guidelines for follow-up and ancillary testing.
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