Cardiac devices present EOL decisions

Ethics principles are similar to ventilators

In recent years, cardiac devices have become a factor in end-of-life decision-making for ethics consultants. When do you turn off a cardiac device that may keep a patient alive after, for example, the patient has become comatose?

Elwood H. "Woody" Spackman, Jr., MDiv, director of the Emory Center for Pastoral Services and co-chair of the Emory Hospital Ethics Committee in Atlanta, says only in the last two or three years has he encountered this dilemma in ethics consultations. And with a burgeoning aging population, such encounters — and the accompanying decision-making — are only likely to increase.

Pacemakers have been around for many years, but the battery life for a pacemaker is short, so there were natural points at which to make EOL and other decisions with those particular cardiac devices, Spackman says.

One of the newer cardiac devices is the left ventricular assist device, or LVAD. LVADs once were used only as a bridge intervention to help patients who were waiting on a heart transplant to survive. However, now heart patients are living with such devices for months or even years.

The decision-making process — and the associated ethics principles — are similar to the decisions made to remove patients from a ventilator, Spackman says.

One basic ethics principle is to do no harm, but the question becomes, "When do you cross the line from doing good to doing harm?"

Spackman gives the example of a patient with a defibrillator as well as metastatic cancer.

"So, you can keep the heart going almost indefinitely with the defibrillator; but you can' treat the cancer — for some reason the cancer is untreatable . . . At what point does keeping this person alive — or a heart beating rather than alive — cross the line to doing harm? You're keeping the body functioning while they're enduring pain; they may be comatose; they may be in a persistent vegetative state, and is that doing more harm than it is good? [The situation is] not a whole lot different than what you were dealing with in the [Karen] Schiavo [case] and the feeding tube," Spackman tells Medical Ethics Advisor. "It's very similar."

For example, with ventilators, " you take a person off a ventilator when it no longer has the potential for restoring a person to a quality of life that they would deem acceptable, or when it becomes medically futile . . . [i.e.] the ventilator is keeping the lungs pumping, but it's not curing — it doesn't give you the possibility for curing the underlying disease.

Decision-making process

In cases such as this, as with many EOL circumstances, the physician — along with the family — has to ask basic questions, beginning with an analysis of all the medical facts.

"What do we know factually about the condition of this individual? Then, we at what this person's express wishes, or their autonomous wishes, would be," Spackman says "The second thing we look at [is], what do we know about the values of this person's life? Has he or she ever expressed what he would want if this should happen to him? Is there a living will? Is there a durable power of attorney for health care? . . .Was this a person of faith? Was this person a person of values? . . . Then you look at the third thing . . . What has been expressed in a living will, durable power of attorney, those dinner kind of conversations?"

Then, Spackman says, "you try to define what is the ethical principle, and we use a conflict between four principles: beneficence, non-beneficence, autonomy, and justice."

Justice issues significant

Justice concerns can become thorny with EOL issues associated with cardiac devices, just as they might with a resource such as a ventilator.

"If you're talking about somebody who is, say, in a coma in an ICU bed with no reasonable hope for recovery, and then you have 10 people in your emergency department that need that ICU bed [and who] could have a reasonable hope of recovery, but can't get there because you've locked down that bed," Spackman explains. "It's a resource issue."

Financial issues come into play, too.

"In terms of an LVAD, what we have struggled with is, who pays for it? Many insurances, including Medicare and Medicaid, will pay for the device itself and the implantation of that, but will not pay for the maintenance, drugs, [i.e.] anti-rejection medications that are required, or the batteries. And you've got an uninsured patient."

The question becomes: does the hospital absorb that cost?

"Those are the kinds of justice issues that we're facing, because the country at large has not decided everybody is entitled to all health care just because it's available," Spackman says.

Source

  • Elwood H. "Woody" Spackman, Jr., MDiv, Director, Emory Center for Pastoral Services; Co-Chair, Emory Hospital Ethics Committee; Adjunct Faculty, Emory Center for Ethics in Public Policy in the Professions, Emory University, Atlanta, GA. E-mail: espackm@emory.edu.