End-of-life and other ethical issues related to pacemaker and defibrillator use in the elderly.

In the past decade, the rate of implantation of pacemakers and cardioverter-defibrillators in the elderly with cardiac impairment has soared. As patients near the end of life, interventions become more complicated and expensive, and less effective. In this context, "informed consent" requires consideration of issues different from those faced in more routine settings. Informed consent requires full disclosure, patient competence, and free exercise of will-but in practice, few patients or their families are in a position to make fully informed decisions about highly complex treatments at the end of life. Physicians continue to bear the responsibility of advising patients about sophisticated interventions or, alternatively, palliative care. Physician training, with its narrow focus on the treatment of disease with drugs and technology, has not prepared physicians to advise patients on issues arising from the availability of multiple interventions at the end of life. Professional societies can fill a gap by developing programs and materials to help physicians treat their dying patients in a high-technology era.

Ethical issues in the management of geriatric cardiac patients.

The cardiologist acted in good faith, which resulted in losing the legal battle, the support of the hospital administration, and the friendship of the pulmonologist.

Ethical issues in the management of geriatric cardiac patients.

Ethical Issue: A hospital's Ethics Committee decides to not give analgesics to a terminally ill patient to relieve her pain.

Ethical issues in the management of geriatric cardiac patients.

Ethical Issue: When referred to hospice care the treating cardiologist believed that his patient would die in a few days. Instead, the patient lived over 18 months.

End-of-life medical treatment of older cardiac patients.

The last decade saw breathtaking advances in the science and technology of heart disease. Fewer patients die from an acute myocardial infarction or acute stroke, or have a sudden death. Thanks to modern technology, people live much longer, but more than half still die of heart disease, mostly chronic. Training programs concentrate on mastery of procedures; the discipline of cardiology has become fragmented into noninvasive, nuclear, invasive, interventional, electrophysiology, heart failure, transplantation, and research. Dying persons expect to receive attention to their spiritual and psychosocial, as well as their physical needs. Ordinary people speak of lack of suffering, no unnecessary interventions that postpone the moment of an inevitable dying, not being a burden on others, and having a sense of control. Their assessment of quality may not match that of doctors who speak in terms of science and technology. Review of the limits of modern technology; understanding of existing laws; the near irrelevance of living wills; the role of the physician in the diagnosis of medical futility; the early indications of depression; and, more importantly, better communication with the patient and his/her loved ones are essential components of the practice of medicine. Cardiologists should differentiate between what should be done and what could be done for their patients.

Routine implantation of cardioverter/defibrillator devices in patients aged 75 years and older with prior myocardial infarction and left ventricular ejection fraction < 30: antagonist viewpoint.

The Multicenter Automatic Defibrillator Implantation Trial (MADIT II) investigators assert that their results justify the placement of artificial implantable defibrillator cardioverter devices in patients aged 75 years and older with prior myocardial infarction and left ventricular dysfunction (ejection fraction of 30 or less). The authors claim that the results of the trial do not justify this conclusion. The majority of patients were male (84%) and aged 64+/-10 years. Also, 2.8% of patients assigned to the defibrillator group and 1.5% had their device removed. Of the latter subgroup, nine patients (1.3%) received a heart transplant. Twelve had their artificial implantable defibrillator cardioverter device deactivated mostly because of terminal illness. Although the study results show a significant reduction in mortality over the control group (absolute reduction=5.6%), almost the same percentage required hospitalization because of manifestation of congestive heart failure (absolute value 5%; p=0.09). Also, 1.8% had lead problems, 0.7% had infections, and the benefits were only seen after the first year. Caution is needed before the results of this study are applied to a much older cohort comprised mainly of women in whom heart transplant is contraindicated and who have multiple health problems, including cognitive impairment. Artificial implantable cardioverter/defibrillator devices are expensive and this study's results need to be duplicated in other comparable cohorts.

Ethical issues in the management of geriatric cardiac patients.

A 92-year-old patient dies less than a year after aortic valve replacement, pacemaker-AICD implantation, renal dialysis, and rehabilitation at a cost of over a half million dollars.