Implantable Cardiac Defibrillator Deactivation During End-of-Life Care in the COVID-19 Pandemic.

People with implantable cardiac defibrillators (ICDs) who are nearing the end of life are at risk for arrhythmias, which activate the ICD and may cause unnecessary shocks and suffering. Because ICDs have enabled more patients to live longer, they often succumb to noncardiac diseases and may be cared for by primary care physicians. Despite published recommendations 10 years ago regarding the management of ICDs during the end of life, over half of patients with ICDs who are dying still have not been offered the choice of deactivation. The Coronavirus disease 2019 (COVID-19) pandemic has complicated this issue and the need to discuss it because of practices that separate patients from loved ones and that modify the usual interactions of patients with doctors and nurses. We offer the following recommendations: (1) the management of ICDs at the end-of-life needs to be understood by all physicians who care for patients with ICDs; (2) discussions about deactivating the ICD should occur while patients have decision-making capacity and are clinically stable, beginning at the time of ICD implantation, then periodically at follow-up appointments, and certainly when a change in the patient's clinical status warrants a reconsideration of the goals of care; and (3) clinicians should compensate for the impediments to communication with patients and families associated with the COVID-19 pandemic, which includes patient isolation and restrictive visitor policies, by using devices that permit visual communication to reexamine goals of care, including defibrillator deactivation, in patients with ICDs who are expected to die.

Ethical issues in gastroenterology research.

Ethical issues have become increasingly important in gastroenterology research. This is for several reasons, including (i) an understanding of how conflicts of interest might affect research, (ii) the influence of the drug and device industries on research, (iii) ghostwriting (taking credit for something you did not write), (iv) the occurrence of ethically inappropriate research and scientific misconduct, and (v) respect for the rights of research subjects. These include the rights (i) to give informed consent to participate after understanding the purposes, risks, and benefits of the research; (ii) to ask questions; and (iii) to withdraw from participation at any time. Notions of doing good (beneficence), avoiding harm (non-maleficence), confidentiality, and, most important, the primacy of the welfare of the patient or research subject can be traced to antiquity. In the modern era, the Nuremburg Code (1947), the Declaration of Helsinki (1964), the Belmont report (1979), and other events and reports have led to the refinement of ethical practices in both clinical and research domains, have reinforced those long observed principles, and have given rise to the newer principles of autonomy and justice. The ethical conduct of research not only promotes good research but also is in the best interests of research subjects, investigators, sponsors, patients, and the public.

When relatives and friends ask physicians for medical advice: ethical, legal, and practical considerations.

Physicians often are asked for advice about medical matters by relatives and friends. These range from requests for simple information to requests for medical opinion and judgment and more substantial involvement by the physician. I comment on the motivations and expectations of the requester and the physician, and the legal, ethical, and practical considerations related to such requests. I recommend: (1) Be clear about the expectations of the requester and yourself, including whether you are being asked for simple factual information, your medical judgment and opinion, or more substantial involvement in the situation. (2) Treat your interactions with relatives or friends with the same professional expertise and judgment as you would any patient. (3) Be aware that a physical examination and especially charging a fee strengthen the establishment of a legal relationship with the requester as your patient. (4) Respect the requester's autonomy and confidentiality and conform to HIPAA requirements where applicable. (5) Be aware of the potential conflict between your roles as a relative or friend and as a physician.