Keywords

FormalPara Case Presentation

A 65-year-old man has been admitted to the hospital for an exacerbation of his congestive heart failure for the sixth time in 18 months. Careful management by your intensive care unit (ICU) team has once again improved his condition and the plan is to discharge him from your ICU. He has an automatic implantable cardioverter defibrillator (AICD), which has shocked him on occasion, and he is grateful for the ‘extra’ opportunities for life the shocks have given. However he has also told you that he is more interested in palliative care, that he is tired of the ‘revolving door’ of his disease process. He notes that time out of the hospital is becoming shorter and although he is not fully aware of the passage of time while in the ICU, his family tells him that the time it takes for him to improve is becoming longer. You offer to have a discussion with him about treatment limitations and suggest a palliative care consult in conjunction with the rest of his family. When the consultation occurs, he agrees to a do not resuscitate (DNR) bracelet but he and his family ask that his AICD remain active through one or two shocks, after which, if the shocks are not beneficial, it would be reasonable to deactivate the defibrillator. Is this an acceptable request? What else would you like to know? What would you like to tell the patient and family?

Introduction

Cardiac devices are becoming more ubiquitous. Current devices are the small, fairly benign pacemakers (PM), the small (and uncomfortable for some) automatic implantable cardioverter defibrillators, and the larger, obvious and life-changing ventricular assist devices (VAD). These devices were all introduced with the intent of helping patients live better lives by assisting the functioning of a failing heart, through the maintenance of appropriate rhythms (PMs and AICDs), rapid defibrillation (AICDs) or assisting circulation (VADs). Each of these devices has helped patients. However, as the end of life approaches, some patients and families view the device as a barrier to high quality end-of-life care. Patients and families will then ask for these devices to be deactivated as death nears.

Initially these requests were considered to be ill-advised, that placement of the device was a permanent, non-negotiable aspect of care. However, with increasing emphasis on patient participation in decision making and with increased understanding of the negative aspects of the devices, there has been a greater acceptance of the potential reasonableness of such requests. Each of these three devices has different functions and a different profile of interference in the patient’s life, so requests for deactivation create different responses in physicians who are being asked about deactivation.

It is important that the physician understand his or her own responses to such requests and the reasons for and against deactivation. With a clear foundation of personal views, a general response to such requests can be crafted that is then fine-tuned according to the individual request. In this chapter, the generic reasons for not honoring a deactivation request will be followed by a brief review of each device with a discussion of the concerns with specific device deactivation. Some suggestions for the deactivation process will be provided.

Reasons to Refuse Device Deactivation

There are arguments supporting the position that these devices should not be deactivated. Deactivation is done via electronic reprograming, thus there is no need to excise the device. Physicians may construe deactivation as worsening the patient’s health, which is not a goal of medicine. Patients and physicians may believe that a device deactivation request is really a disguised suicide attempt. Physicians assert that the written order for deactivation would be assisting in the suicide. If the order writing is not considered suicide assistance, then it is euthanasia. The written order will allow for the killing of the device-dependent patient. The Heart Rhythm Society (HRS) considered these concerns and in 2010 issued a consensus statement that explains why deactivation should not be construed as assisting suicide or euthanasia [1]. HRS acknowledged conscientious objection by physicians with the caveat that care of the patient should be transferred to a provider who is willing to honor the request.

Currently, emphasis is placed on patient-centered or shared decision making, which focuses on understanding the goals of the patient and designing a plan of care that is as respectful of those goals as is possible [2]. When patients are asked about how they would like to die, they most frequently describe a ‘low tech’ death – at home, surrounded by loved ones and being kept comfortable. Patients and families may believe the devices unnecessarily prolong cardiac function as the rest of the body is shutting down, thus extending the dying process beyond that which might otherwise be expected.

The HRS statement declares that decisional patients have the power to assess ongoing therapies particularly in light of their changing health status to determine the continued usefulness of the particular therapy. If the patient is not decisional, then information about the appropriateness of deactivation should be shared with the legally authorized representative (LAR) of the patient. If there is no LAR, then family members engaged in the care of the patient should be involved in end-of-life conversations. In this chapter, “surrogate” will be used to indicate LAR or engaged family members. When receiving a terminal diagnosis, the patient may decide that cardiac devices are no longer as beneficial as they once were. HRS analysis supporting deactivation focuses on the patient’s perception of device benefits and burdens in the context of the patient’s goals and values for end-of-life care.

Although the HRS consensus statement does not explicitly mention VADs, the overarching term used to describe PMs and AICDs is ‘cardiovascular implantable device,’ which easily includes VADs. Ethical analysis by Mueller et al. supporting VAD deactivation proceeds similarly to the HRS analysis [3]. Both focus on patient driven assessments of benefits and burdens and a legally supported distinction between killing and allowing to die.

Pacemakers

Although PMs are the oldest of the three cardiac devices, familiarity with the device has not created the most robust consensus about deactivation. PMs continue to create unease when physicians are asked about deactivation. Usually, the longer a medical intervention is used, the easier it becomes to consider its removal. For example, initial requests for ventilatory support removal were met with strong opposition. Now most clinicians are reasonably comfortable with such requests. This is also true of dialysis discontinuation as well as artificial nutrition and hydration, to a large extent. The fundamental issue that creates a negative response to PM deactivation requests is that there is no apparent burden to its continued functioning. The PM is small, with no external wires and it paces in an unobtrusive manner. There is the potential for infection at the time of placement and lead fracture may occur, but rarely. Faulty pacing can be detected and the PM is easily reprogramed for better pacing. Battery lifetime is now about 10 years and battery replacement is usually an outpatient procedure.

Huddle et al. suggest that since there is no active role played by a physician once the PM is implanted, there can be no deactivation as this would be either assisting suicide or euthanasia [4]. This denies the ongoing care a patient receives after PM placement. If Huddle’s analysis is accepted, devices might return to short-term batteries, wherein a discussion could be had before each battery replacement. This would be similar to the placement of a timer on a ventilator as described by Kinzbrunner, thus requiring the active intervention Huddle deems necessary for deactivation [5]. Miller et al. have suggested that withdrawal of care is indeed killing, that we have created moral fictions to ease our discomfort with such actions, and that it is acceptable in some circumstances to do so [6].

Some surrogates are not aware that a PM can be deactivated; other surrogates may view the PM as an impediment to a natural death by prolonging the patient’s life in an inappropriate manner – the forced beating of a heart in a dying patient. This certainly is the contention put forth by Butler [7]. Physicians find it difficult to deactivate a device that seemingly has no downside – PMs do not limit the patient’s day-to-day activities, unlike an AICD or a VAD. The physician may believe that the PM only enhances cardiac function so that the patient can enjoy life. However, at the end of life, the PM may not be furthering opportunities for the enjoyment of life [8, 9]. To deny deactivation is to insist that neither the physician nor the patient can come to a different definition of health care as the patient’s health status changes.

Deactivation might not create any change in a dying patient’s health, which might be disappointing to the patient and surrogate if that is what was anticipated. An intrinsic rhythm of 40 may be sufficient for a bed bound patient. Or, there may be increasing symptoms once the PM is deactivated, such as fluid retention. The slow intrinsic rate may prevent sitting or standing easily. Of course if the patient had undergone ablation prior to the PM implantation, there might not be any rhythm and the non-paced heart will stop.

These varied outcomes should be discussed with the patient and surrogate before the PM is deactivated. Whitlock et al. reported that death subsequent to deactivation occurred within “a few hours” [10]. Mueller et al. also reported that the time to death was less than a day [11]. Contingent plans for supporting the patient after deactivation should be created since there are so few reports of what actually occurs. Palliative care consultation can provide assistance in symptom management once the PM is deactivated as well as support of the family. It is also important that all of the staff providing care for the patient understand the rationale for the deactivation. When considering PM deactivation, the conversation ought to include a discussion of a do not resuscitate order (DNR), which should be in place before the deactivation process occurs. Clear documentation of the reasons for the deactivation must be available for the person who will deactivate the PM, as well as the actual order for deactivation. This will mitigate concerns about the deactivation decision particularly if the request is made during one shift with one set of physicians and the actual deactivation does not transpire until another shift with another set of physicians.

Automatic Implantable Cardioverter Defibrillators

These devices became available in the 1980s and were approved by Medicare shortly thereafter. As indications for the AICD have expanded, an increasing number have been implanted every year. These devices are about the same size as a PM. In actuality, many devices are currently manufactured with the ability to function as both PM and AICD. The potential short-term complications are the same as for PM – infection and lead fracture. However, what became well known within cardiology circles shortly after AICDs were implanted is that some patients are completely aware of the shocks they receive [12]. At their most intense, the shocks are described as mule kicks or baseball bats to the chest. Cardiologists do alter medication regimes as well as reprogram the device so that the shocks are fewer and less uncomfortable, but these maneuvers do not always help the patient. Some patients will alter their lifestyle in the hope of fewer shocks. They may give up once pleasurable activities to avoid the traumatic shocks. Various counseling modalities have been useful in diminishing patient anxiety, however the counseling does not decrease the number of shocks [13]. It is important to remember that not all patients who have an AICD implanted are shocked and that not all patients who are shocked are bothered by the shocks.

As patients age and other chronic illnesses become more prominent, patients may decide that the AICD is no longer a welcome treatment modality. If there is a new life limiting diagnosis, patients may find the potential swift trajectory of death from a sudden cardiac arrhythmia more appealing than the long, slow downward trajectory of the newly diagnosed terminal illness. A device that initially was welcome as preventing sudden cardiac death is now unwelcome as preventing sudden cardiac death. On this basis and perhaps especially if the patients have experienced significant unpleasantness with the shocks, the patients may request deactivation of the AICD.

Paola et al. have suggested that the AICD is a biofixture, thus it has become part of the patient and ought not be deactivated [14]. However, Sulmasy counters that the location of the device is not in and of itself reason to eschew deactivation [15]. HRS also does not accept location of a device as a reason for deactivation refusal.

When patients are asked to describe a good death, many will talk about dying in one’s sleep, presumably of an arrhythmia. Thus, deactivating an AICD would now make this ‘good death’ more possible. Some clinicians believe that it is assisting suicide to deactivate the AICD. In the case of a terminal diagnosis and a decisional patient’s request for deactivation, this is not assisting suicide but demonstrating respect for patients. If the clinician has concerns about a patient’s abilities to make such a decision, it would be reasonable to ask for a psychiatric evaluation.

The conversation with a patient who is requesting AICD deactivation ought to include the information that deactivation does not guarantee a quick death from a fatal arrhythmia. There might be an arrhythmia that is not fatal - making the patient worse off but not dead. There may be no arrhythmia after the device is deactivated, especially if it fired infrequently or not at all. So, in spite of deactivation, the patient may experience the downhill decline he or she hoped to avoid. Thorough conversations with the patient and surrogate describing these possibilities before deactivation enable better decision making. Concerns can also be addressed with input from the palliative care team [16, 17]. DNR orders should also be clarified during the conversation about deactivation.

Ventricular Assist Devices

VADs were initially introduced as a bridge to heart transplantation but have become destination therapy for some patients. The implantation of a VAD is high-risk surgery, with significant complications – strokes, multisystem organ failure, bleeding and infections [18]. The need for post placement anticoagulation keeps the patient at risk for bleeding - gastrointestinal bleeding can be chronic in nature and a cerebral bleed can, of course, be devastating. External wires create an ongoing increased risk for infection. Management of the device requires support from a caregiver, family or friends as well as the advanced heart failure team.

Physicians may be reluctant to deactivate these devices for the same reasons as PMs and AICDs – deactivation is assisting suicide and perhaps even more so than AICDs, deactivation really will (within a short period of time) directly cause the death of the patient. This latter objection, the legal concept of proximate cause, may be a powerful influence in the consideration of VAD deactivation but it is balanced by the unwanted, unacceptable devastation some patients experience with placement.

Unlike the surgery for PM or AICD placement, VAD placement is major surgery with the above-mentioned complications that can permanently impair the patient. Deactivation has more rapidly become acceptable perhaps because physicians have learned from their experiences with PMs and AICDs. Physician concerns with assisting suicide and euthanasia are the same as with PMs and AICDs so the ethical and legal support framework provided by the HRS is applicable and valid. There are articles describing VAD deactivation [5, 19]. Although it is a small sample, Mueller et al. deactivated 20% of VADs placed in a nearly 6-year time frame [5]. None of the requests for deactivation were denied. Mueller et al. suggested that familiarity with deactivation of PMs and AICDs allayed concerns about the “permissibility of meeting these requests” [5]. A significant addition to their approach to VAD placement is that all the potential recipients now “receive consultation with a palliative medicine specialist who engages the patient in the process of advance care planning” [5]. The potential recipients are encouraged to voice their wishes should there be “device failure, catastrophic complications, development of a secondary comorbid condition, or ongoing poor quality of life” [5].

As palliative care has become an increasingly valuable part of patient care, particularly in ICUs, the tough conversations needed to explore VAD deactivation requests can be collaborative in nature with input from both the palliative care team as well as the ICU team in conjunction with the patient or surrogate [20, 21]. Furthermore, the palliative care team can assure the patient that management of all symptoms, not just cardiac symptoms will be in the plan of care. Integration of palliative care into heart failure care has been well described in the literature [17, 22, 23]. If there are wishes to transfer to home or residential hospice care, again the palliative care team has the expertise to coordinate such a request including a discussion of holding off on the VAD deactivation until the transfer has occurred.

Although not inherently needed in each deactivation conversation, an ethics consultation may provide value particularly when deactivation is new to the team or institution. VAD placement is performed after a multidisciplinary advanced heart failure team has thoroughly evaluated the patient and the team continues to monitor the patient after placement, thus there is continuity of care with ongoing assessments of the VAD’s value.

VAD deactivation is either turning off the device or letting the batteries run down. Although VAD patients are dependent on the VAD, there still is some functioning heart muscle, so it is inappropriate to assume that VAD deactivation will cause immediate death. Palliative care can help support the patient and the family during this time. Again, DNR status should be discussed and documentation of the reasons for the deactivation is necessary to avoid misunderstandings.

Device Deactivation Process

Personal Values

The very first concern in considering device deactivation is the physician’s response to such a request. Awareness of the potential for deactivation is increasing. A physician should anticipate such requests and reflect upon personal values. HRS acknowledges conscientious objection, however HRS supports an obligation to transfer care to a colleague willing to deactivate, should the patient or surrogate ask for deactivation. The physician also has an obligation to inform the patient of his or her non-deactivation stance from the start of the patient-physician relationship so the patient has the opportunity to seek another physician with an approach to deactivation that is in more alignment with the patient’s goals and values.

Timing of General Information: From Physician to Patient

As HRS advocates, during the pre-implantation conferences, there ought to be a brief statement to the effect that as the patient’s health status changes deactivation is a possibility. It is difficult for some physicians to inform patients that a device can be deactivated before it has even been placed, but a short sentence is all that is needed during the initial informed consent conversation. If appropriate, this is also the time for the physician to inform the patient that deactivation will not be performed because of conscientious objection. This information provides the patient the opportunity to find another provider.

PM and AICD placement surgeries are considered minor surgeries and ongoing care is transitioned from the implantation specialist to the primary cardiologist to the primary care physician. If these physicians are uncomfortable communicating deactivation possibilities, each may assume another has discussed the information such that a patient remains uninformed. Butler and Puri advocate for “an ethical responsibility to inform patients that devices can be painlessly deactivated, when in the patient’s view, burdens outweigh benefits” [24]. It is important to remember that informing a patient is not inherently an agreement to do so.

The heart failure team, who regularly communicate with each other and the patient, manages the patient who undergoes VAD placement surgery. This continuity of care increases the likelihood that patient and surrogate are informed of the deactivation possibility. In some institutions, palliative care specialists are part of the team and they can help with deactivation information [21].

As the device parameters are adjusted, as batteries are changed and as the patient’s health status changes, simple reminders are appropriate. If a patient or surrogate asks more questions about deactivation, then a fuller description of what would likely happen is appropriate. If the physician will not deactivate a device, the patient should be so reminded, along with a referral to another physician who would be willing to honor the request.

Timing of General Information: From Patient to Surrogate and Physician

During the informed consent conversation for implantation, the patient should be encouraged to fill out an Advance Directive (AD), if he or she has not already done so. If the AD names a surrogate, the patient should have discussions with the surrogate about when, if ever, deactivation should be considered. Pasalic et al. conducted a 2-year retrospective review of patients who underwent PM implantation to determine whether or not the patients had an AD and if so, comments if any about the PM [25]. Over half of the 205 patients had ADs, but only one AD mentioned the PM [25]. While this might be a reflection of lack of knowledge about the potential for PM deactivation, Tajouri reviewed the content of ADs in patients with AICDs and found similar results [26]. Thirty percent of the patients who had AICDs implanted during the yearlong study had ADs and only two ADs specifically mentioned the AICD [26].

Deactivation requests may become a consideration when the patient is given a second life limiting diagnosis, the first being the heart disease. This is another opportunity to urge the patient to update an existing AD or create one. Information in the AD should include when, if ever the patient would deem it appropriate, to deactivate the device. Written guidance is beneficial when patients cannot communicate and there is general unease about deactivation. Placing the information in the patient’s chart can enhance a patient-physician alliance should the time come for a specific discussion about deactivation.

Education of Patient and Family

Although it is increasingly common for a patient to be aware of deactivation possibilities, there are still many patients who have not been so informed. Some patients may be surprised and grateful for the option, other patients may be uninterested in which case no further conversation is needed. When the medical team, the patient and surrogate all agree that device deactivation is the most appropriate care for the particular patient, there ought to be an educational conference about the process of deactivation. The patient and surrogate may assume that when the device is deactivated, the patient dies immediately. This may or may not happen. It is most likely to happen, based on the few reports available, for a PM or a VAD. An AICD may or may not shock frequently so there may be a more variable time frame to patient death. This educational session is an excellent time to introduce the palliative care specialists, if it has not already happened. While the immediate topic is providing care for the patient during and after deactivation, it is important to remember that the patient may be experiencing noncardiac symptoms that the palliative care team can help manage. Reported PM and VAD deactivation have been followed by patient death within a day, so the patient might remain in the hospital.

A patient may wish to go home with hospice care or go to a residential hospice. If so, it is reasonable to maintain the device until the transfer occurs, but this must be discussed with the patient and the family. DNR status must also be explicitly addressed. With careful planning and thorough communication with the receiving parties, successful transfer may be possible. There are a few protocols for the deactivation process [27], so if a hospice is new to this kind of care sharing of information will enhance the likelihood of a successful deactivation. Conscientious objection from hospice nurses and the allied health care professionals who will be called upon to do the deactivation should be supported, but there also must be reassurance that there will be health care providers who will honor the request at the receiving institution before the transfer is made.

Deactivation at Home Hospice or Residential Hospice

If home or residential hospice is preferred and is feasible, the patient and family should meet the palliative care team who will assist in the transfer of care and help coordinate the deactivation in the new location. Allied health care professionals are more likely to deactivate in nonhospital settings, so it becomes important for these personnel to understand the reasoning for the deactivation [28]. Good documentation is key. The scheduling of the deactivation should be in accord with plans the family may have for saying their goodbyes as well as the work schedule of the deactivator. Clear communication about role responsibilities is vital. Palliative care teams may be new to the deactivation of cardiac devices, but they are not new to the transfer of care to hospice, to ensuring the most comfortable death possible and to encouraging the difficult end-of-life conversations. Having the palliative care team involved, whether an in-hospital or out-of-hospital deactivation is planned, will allow for the best possible conversations with the patient and family, including the possibility of the patient not dying immediately after deactivation. The palliative care team will also address the noncardiac symptoms of the patient.

Deactivation at End of Life: Pacemakers

As described earlier, this is the most controversial device to deactivate. The process of deactivation involves resetting the PM to parameters such that there is no device pacing. Patient and surrogates must be informed that the time of death cannot be completely predicted. There is no active registry of deactivation stories; of those that are described, death occurred within a day. Concerns have been raised that if a patient is bedbound, the deactivation may not accomplish much since little is known about what kind of cardiac output is necessary for such patients. The patient may develop a slow intrinsic rhythm that prevents the anticipated death, but does cause more heart failure. As Bevins explains, the pacemaker was placed for a cardiac disease so heart failure should not be a complete surprise [29]. If palliative care has been involved, they will of course be available to manage new symptoms that appear after the PM is deactivated. Before the PM is deactivated, there also needs to be a conversation about a DNR order, if one has not yet been written. Deactivating a PM and writing a DNR order are linked, but each requires formal acknowledgement so there is no miscommunication.

Deactivation at End of Life: Automatic Implantable Cardioverter Defibrillators

The potential for painful shocks is well known and much work is done to minimize them. A patient can have his or her medications adjusted, have the threshold for defibrillation adjusted and the patient is encouraged to undergo psychological support to diminish the trauma of the shocks. As the patient’s heart disease continues to progress, if the patient receives another life limiting diagnosis or if the number of shocks increases in spite of excellent medical management, a patient may declare that the benefits of the device are no longer worth the burdens. A patient anticipates that if there are no defibrillatory shocks, there will be a lethal arrhythmia with death ensuing immediately. This may not occur and has to be explained and explored with the patient or surrogate who are requesting deactivation. The AICD can be deactivated, and the patient may not suffer a lethal arrhythmia, thus continuing to live as has been reported by Buchhalter et al. [30]. The AICD can be deactivated and the patient may suffer a non-lethal arrhythmia, which may leave the patient more debilitated, but not dead. If the patient is actively dying and the AICD is deactivated, there will be no further shocks and the more natural death being sought by the patient and surrogate is more likely to occur.

If the device implanted is being used as both a PM and an AICD, then all functions of the device must be reviewed with the patient or surrogate. Some physicians are willing to deactivate the defibrillator but not the PM. This plan must be presented to all participants for understanding and approval. If the patient or surrogate wishes to have all functions deactivated, the physician must have a further discussion with all participants or assist in the orderly transfer of care if there is conscientious objection by the physician. DNR status is part of the deactivation conversation.

As with PMs, all of this information must be documented so that all team members participating in the care of the patient can understand the decision-making process and the care plan.

Magnets for PMs and AICDs

If the plan is for the patient to remain in the hospital during and after the deactivation, then there will be access to a cardiology team that is familiar with the patient as well as the device and can aid in correcting unexpected deviations from the plan of care. If the patient is transferred to home hospice or residential hospice, especially if this is new territory for the hospice team, education about the use of magnets is imperative. Magnets create asynchronous pacing, however magnets are also able to stop the defibrillator function of an AICD [31]. If there is a single device that is both pacing and defibrillating, careful discussion about what is being deactivated (tachyarrhythmia pacing, bradyarrhythmia pacing, defibrillation – some or all) and the effect of a magnet on each function is needed to assure that the planned deactivation is achieved.

Deactivation at End of Life: Ventricular Assist Devices

At minimum, advanced heart failure teams are composed of cardiologists, surgeons, intensivists, social workers, psychologists and nurses. Most of these clinicians are involved in all aspects of patient care - evaluation, implantation and post-implantation management. Ethicists, chaplains and palliative care specialists may also participate in patient care. Although the team may experience some reluctance to immediately honor the patient’s request for deactivation, the ongoing relationship with the patient creates a real-time understanding of the patient’s concerns.

After deactivation there may be some heart function left, but it likely will not be sufficient to sustain the patient for many days. Mueller et al. reported on 14 deactivations, and all died within a day [3]. Brush et al. reported death occurred within 20 minutes [19]. If a patient or surrogate wishes to transfer to home or residential hospice, the physicians must plan for the orderly transfer of care in conjunction with the family. This planning should cover among other topics, refraining from deactivation until after the transfer, DNR status and exactly who is going to deactivate. Unfortunately, a patient may not be stable enough for transfer and the patient and family will have to be so informed.

Future Concerns

Kramer et al. elicited nursing concerns with deactivation [32]. Nurses are the providers who spend the most time at the bedside, so their observations ought to be examined closely. Nurses want better communication about deactivation at the implantation conference, at the time of life limiting events and when a device is deactivated. Nurses are physician allies who provide important information about patient and family concerns. They help defuse conflicts between physicians and families, so acting on these observations about cardiac devices will most likely result in an enhanced partnership. Brush et al. interviewed VAD patient caregivers who appreciated the comprehensive end-of-life care plans but also advocated for increased education for the hospice providers who were not always as savvy as the caregivers [19].

As these devices continue to be used, as the deactivation potential becomes more widely known and as hospice care becomes more sought after, sharing of successful deactivation protocols will enhance the dying experience for patients and families. It must be remembered that the protocol should be device specific – each device treats a different aspect of cardiac disease. Plans for transfer of care in cases of conscientious objection must be in place.

It would also be beneficial to continue reporting on patient deaths after device deactivation to further the understanding of how to approach deactivation. For example, concerns are raised about heart failure after deactivation of a PM, however the few reports available do not indicate that this occurs. A formal registry where data could be archived would inform the physicians of the more common scenarios after deactivation.

Conclusion

When Karen Ann Quinlan’s parents requested the removal of her ventilator in 1975, there were significant objections to the request from the medical community as well as the lay community. The issue of removal of medical therapies has been reasonably settled with an understanding that patients have an ethically well-grounded ability to refuse medical therapies even if removal will likely result in their death. In the last 30 years, this controversy, although settled, appears to have reinvented itself as cardiac devices are increasingly used to enhance the lives of patients with heart disease. As the devices have become more common, specialty societies, ethicists and the lay have for the most part, again come to the understanding that patients can ask to have therapies removed, even after started. Physicians may object, but do have an obligation to assist in orderly transfer of care. In the future, when implantable hearts are available outside of research protocols, these concerns will again come to the fore. Analysis of the concerns raised by current devices as well as the concerns raised in the research trials of artificial hearts will enable the formulation of ethically and legally sound deactivation protocols [33, 34]. As always, there will be difficulties, but we can best move forward by examining our past, learning from the prior errors and anticipating some of the new concerns.