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J Med Ethics 39:94-97 doi:10.1136/medethics-2012-100613
  • Clinical ethics
  • Paper

Documented consent process for implantable cardioverter-defibrillators and implications for end-of-life care in older adults

  1. Sally Rigler4
  1. 1Department of Internal Medicine, KU Medical Center, Kansas City, Kansas, USA
  2. 2Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
  3. 3Department of History & Philosophy of Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
  4. 4Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
  1. Correspondence to Dr Sally Rigler, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS 66160, USA; srigler{at}kumc.edu
  • Received 1 March 2012
  • Revised 28 September 2012
  • Accepted 10 October 2012
  • Published Online First 8 November 2012

Abstract

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at risk for life-threatening heart arrhythmias, and their use is increasingly common. However, these devices also confer risk for delivery of unexpected painful shocks during the dying process, thus reducing the quality of palliative care at the end of life. This scenario can be avoided by ICD deactivation in appropriate circumstances but patients will remain unaware of this option if not informed about it. It is not known how often end-of-life implications are discussed with patients prior to ICD implantation, when focus is primarily on the short-term potential complications of the device placement procedure itself. We conducted a retrospective chart review to determine how often end-of-life implications were discussed with patients as part of the informed consent process. We evaluated consent forms and related other chart documentation for 91 patients (ranging from age 60 to 89 years) undergoing first-time ICD placement at a mid-western academic medical center from 2006-2008. Only one chart documented any discussion of end-of-life implications, in a case where the issue was raised by a patient who noted that quality of life was their main focus. Consent was provided by a health care surrogate in only four of the 91 cases. In conclusion, patients giving consent for ICD implantation may be uninformed about the device's potential future impact on end-of-life care, the dying process, and the option for device deactivation. Truly informed consent requires that both short- and long-term potential implications be reviewed with patients.