Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients

Med Sci Law 2010;50:40-44
doi:10.1258/msl.2009.009006
© 2010 British Academy of Forensic Science

 

This Article
Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients

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Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients
Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients

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Aine McGeary MRCP LLB *  and
Anselm Eldergill LLB 


* Healthcare Law Department, Eversheds (Solicitors) and Trust Fellow, Gateshead Health NHS Foundation Trust
President of the Mental Health Lawyers Association, President of the Institute of Mental Health Act Practitioners, Consultant, Eversheds (Solicitors), Tribunal Judge, UK

Correspondence: Dr Aine McGeary, Eversheds LLP, Central Square South, Orchard Street, Newcastle upon Tyne NE1 3XX, UK. Email: AineMcgeary{at}eversheds.com




Abstract

TOP

Abstract
Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

The number of patients receiving pacemakers and implantablecardioverter defibrillator (ICD) devices continues to increasedramatically. In this paper, the issue of when it is appropriateto deactivate these devices if the patient becomes terminallyill and the medicolegal implications of this action are examined.This appears to constitute a withdrawal of treatment. However,the issue has never come before the courts and therefore nomedicolegal guidance exists on the point. This paper highlightsa lack of knowledge among health-care staff regarding switchingoff electromechanical devices in terminally ill patients. Wepropose some guidance and recommendations for dealing with thisissue when it arises in practice, and highlight some importantdifferences between pacemakers and ICDs that will influencedecision-making. Conclusions are expressed regarding how thisissue should be dealt with in the postmortem setting and inthe antemortem setting, where the issue of capacity and consentwill influence decisions regarding deactivating these devices.





Introduction

TOP

Abstract

Introduction
Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

Pacemakers and implantable cardioverter defibrillator (ICD) devices fall into the definition of biomedical technologies which assist or replace a vital function of the body that has been temporarily or permanently damaged, so they can be a form of life support.1 During one study period between 1990 and 2002, 2.25 million pacemakers and 415,780 ICDs were implanted in the USA.2 Their role as electromechanical devices necessary to sustainlife and improve quality of life is well recognized. However,the issue of when it is appropriate to deactivate these devicesand the legal implications of this action are less clear. Itis the opinion of the authors that this is a withdrawal of treatmentfor a patient, but it would appear that the issue has neverbeen considered by the courts. Circumstances in which it maybe necessary to deactivate these devices include after the patient’sdeath for health and safety reasons, or where the patient isdying of a terminal illness. We suggest that there are somedifferences between these devices that will influence the decisionas to whether they should be deactivated in the circumstanceof terminal illness. While there are published guidelines forplacing implantable cardiac devices, there are no defined standardsto inform the complex decision to withdraw this type of treatmentfrom terminally ill patients.





Assisted suicide, euthanasia and murder/manslaughter

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…
Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

A right to life is protected in both criminal and civil English law. While it is no longer a criminal offence to attempt suicide,3 it is an offence to incite, aid, abet, counsel or procure suicide.4

In relation to euthanasia, case law has emphasized that taking active steps, such as administering a drug, to end another’s life, no matter how humanitarian, remains murder.5 Case law has also established that it would be unlawful to perform an act where the doctor’s primary intention is to bring about the patient’s death.6

Murder is a common law offence defined as ‘unlawful killing with malice aforethought’.7 For a person to be convicted of murder they must have the necessary mens rea, which is the intention to kill or to cause grievous bodily harm. This is to be differentiated from the common law offence of manslaughter, where the necessary intention to kill is absent.





Pacemakers

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers
ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

Contrary to popular belief, pacemakers do not necessarily take over the job of keeping the heart beating and are on standby much of the time. A pacemaker is unlikely to prolong the life or suffering of a terminally ill patient.8 Lewis et al.9 showedwhen comparing pacemaker-dependent and non-dependent patients,that there was no difference in the time between therapy discontinuationand death. Thus, continuing patient therapy in terminally illpacemaker-dependent patients did not significantly extend theirlives compared with non-pacemaker-dependent patients.

The deactivation of a pacemaker, where it is a life-sustaining device, is a withdrawal of treatment. The courts’ position in relation to withdrawal of treatment where the patient lacks capacity to consent is clear – treatment can only be withdrawn if the patient’s condition is terminal, the prognosis is hopeless and the withdrawal of treatment is in the patient’s best interests.10 However, we suggest that switching off a ventilator for a patient in a persistent vegetative state (PVS) differs from deactivation of a pacemaker in a terminally ill patient. The ventilator is keeping the patient in a PVS alive, whereas in the majority of cases a pacemaker device will eventually prove ineffective in a terminally ill patient. The normal process of dying will result in the heart muscle eventually being too weak to respond to any pacemaker stimulus. McQuoid-Mason11 suggeststhat the result of death of the patient should be regarded asdue to the underlying illness or injury, rather than the deactivationof the pacemaker and suggests that legally there is no causallink between the reduction of the pacemaker activity and thedeath of the patient.

Situations may also arise where a patient’s pacemaker is deactivatedand this precipitates cardiac failure or arrhythmias which willnot only reduce the patient’s quality of life but also may eventuallyresult in the patient’s death. It is our view that this wouldnot satisfy the necessary legal threshold, which is that theact is in the patient’s ‘best interests’.

It is incumbent on the doctors looking after the patient’s careto ensure that all aspects of the decision to deactivate theirpacemaker are addressed with the patient. Where a patient isterminally ill and has capacity to consent to deactivate theirpacemaker then this may present some problems. Of particularconcern would be the situation where a patient who appears tohave capacity to consent to their pacemaker being switched offmay also have an underlying depressive illness in associationwith their terminal illness and wishes to die. In this situationdeactivation of the patient’s pacemaker could in theory be assistingin the patient’s suicide.

Although it may be legally acceptable for a patient to request their pacemaker be deactivated, it should be emphasized to them, as part of the informed consent procedure, that it may result in a reduced quality of life. Braun et al.12 concluded thatthere are uncommon, but potentially severe, adverse effectsof disabling a pacemaker, and therefore pacemakers should generallybe left intact in terminally ill patients. The overall conclusionof the study was that to tamper with a pacemaker in a terminallyill patient is unethical and illegal, whereas the matter istotally different for a patient with an ICD.

We would also see difficulties arising in a situation where a patient is terminally ill and lacks capacity to consent to deactivate their pacemaker. This situation causes concern as deactivating the pacemaker may be a withdrawal of treatment which brings about and, by precipitating arrhythmias or cardiac failure, may even bring forward the patient’s death or a reduced quality of life.13 This is significant because it is an established principle that the patient’s likely quality of life is a relevant consideration where that patient lacks capacity to decide for themselves whether a particular medical treatment is more burdensome than beneficial.14 In this situation, a best interests applicationto the Court of Protection would be advisable, given the lackof legal precedent.





ICD devices

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices
Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

An ICD device is a small, battery-powered electrical impulsegenerator which is implanted into patients who are at risk ofsudden cardiac death due to ventricular arrhythmias. The deviceis programmed to detect cardiac arrhythmias and to correct themby delivering a jolt of electricity. ICDs differ from pacemakersin that pacemakers are generally designed to consistently correctbradycardia, while ICDs are often permanent safeguards againstsudden cardiac abnormalities.

With indications for ICDs increasing, more patients are receiving such devices.15 Clinical guidance is deficient regarding deactivation of ICDs in patients with terminal illness.16 We suggest that the situation in relation to ICDs differs from the situation in relation to pacemakers in that:

  • ICD discharges are both physically painful and emotionally distressing to most patients, and may impose an additional symptom burden;17
  • There is a theoretical risk of the patient’s care-givers receiving an accidental shock if they are in direct close physical contact with the patient;18
  • Terminally ill patients may be at increased risk of ICD shocks due to electrolyte disturbances, hypoxia and heart failure.19,20

Bearing these factors in mind, were this issue to comebefore the courts it is likely that they will apply the sameprinciples as they have done in the past in cases involvingwithdrawal of treatment in patients who were in a PVS. Theoreticallyat least, the argument in relation to ICDs as to what is inthe patient’s best interests is probably more persuasive thanthe argument that could be put forward in relation to pacemakers.

Basda et al. concluded that deactivation of an ICD is considered legally, morally and ethically acceptable in terminally ill, dying patients. However they stated that deactivation of pacemakers and needless premature deactivation of ICDs to cause death is legally, morally and ethically wrong and if done without the knowledge of the patient it should be considered active involuntary euthanasia.21





Postmortem

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem
Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

In the postmortem setting the deactivation of a pacemaker device or ICD should pose no medicolegal issues. Indeed, from a health and safety perspective it is often necessary to ensure this procedure is carried out before the body is disposed off, e.g. where the body is to be cremated. The European myocardial infarction amiodarone trial and the Canadian amiodarone myocardial infarction trial have shown that pacemakers can continue to work in dead patients.22 The Medicines and Healthcare Products Regulatory Agency (MHRA) issued a medical device alert for the attention of clinicians and mortuary personnel who remove ICDs postmortem in September 2008.23 The advice contained in this alert wasthat ICDs should not be removed without first disabling allhigh-voltage shock therapies. The concern for the MHRA whichtriggered the medical device alert was that it had receiveda number of reports of electric shocks sustained by mortuarypersonnel and medical practitioners during the removal of ICDsafter death.





Capacity and consent

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent
Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

A patient’s request to deactivate their pacemaker or ICD may be honoured in light of the principle of autonomy.24 Mueller et al.25 retrospectively studied medical records for six terminally ill patients who requested withdrawal of pacemaker or ICD support. They concluded that granting terminally ill patients’ requests to withdraw unwanted medical support is legal and ethical, and that death after withdrawal of support is attributable to the patient’s underlying pathology and is not the same as physician-assisted suicide or euthanasia. The ACC/AHA/HRS 2008 Guidelines address the issue of electromechanical devices in terminal care and acknowledge it is an increasingly encountered clinical issue that needs further research and the development of guidelines for device management in patients with terminal illness.26 Theystate that honouring requests for withholding or withdrawinglife-sustaining treatments is an integral aspect of patient-centredcare and should not be regarded as physician-assisted suicide.

Where a patient has consented to their pacemaker or ICD beingdeactivated, we would suggest that the person carrying out theprocedure should verify that the patient has given written consent,that the patient’s doctor has recorded in the clinical notesthat the procedure is a necessary part of the patient’s treatment,that the patient’s doctor is responsible for the treatment throughoutand that the treatment is carried out in accordance with theirdirections. The doctor responsible for the patient’s care should,as part of the informed consent procedure, make the patientaware of the potential symptomatic sequelae if the device isdeactivated, and arrangements should be in place for palliativecare.





Incapacity and no consent

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent
Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

The Mental Capacity Act 2005 sets out the test for incapacity. It states that a person must be assumed to have capacity unless it is established that he lacks capacity,27 and that an act done or decision made for and on behalf of a person who lacks capacity must be done or made in his best interests.28

The considerations that must be taken into account in assessing what is in the patient’s best interests are set out in Section 4 of the Act.29 Of particular relevance to this discussion is Section 4(5) which states:

‘where the determination relates to life sustaining treatment he must not, in considering whether the treatment is in the best interests of the person concerned, be motivated by a desire to bring about his death.’30

 

Life-sustaining treatment is defined as ‘treatment which in the view of a person providing healthcare for the person concerned is necessary to sustain life’.31

In the situation where the patient is terminally ill but doesnot have capacity to consent to their pacemaker or ICD beingdeactivated then we would reiterate that this is an untestedarea of law. The patient’s incapacity should be confirmed byensuring that it satisfies the statutory test set out in Sections2 and 3 of the Mental Capacity Act 2005.

If the patient has made a valid advance decision in writingwhich states that they consent to their pacemaker or ICD beingswitched off in the circumstances of terminal illness, and thedoctor responsible for the patient’s treatment has made theappropriate documentation outlined above, then we feel it isunlikely that any medicolegal issue would arise.

Under Section 9 of the Mental Capacity Act, a donor can confer on a donee the authority to make decisions concerning their personnel welfare in a lasting Power of Attorney.32 This wouldmean that a donor could authorize a donee to refuse life-sustainingtreatment on their behalf. Therefore a situation may arise inpractice where an incapacitated terminally ill patient may haveappointed an attorney who may have the authority to authorizedeactivation of their electromechanical device. Were this tooccur in practice it would be important to confirm that thedonor lacks capacity to make the decision for themselves, thatthe donee does have this authority that is set out clearly inan appropriate, registered, power of attorney, and that deactivationis in the patient’s best interests. In cases of doubt, an applicationshould be made to the Court of Protection.

Section 5 of the 2005 Act applies where there is no advancedecision, Lasting Power of Attorney or court in existence toguide practitioners. In general terms, it provides that thereis no legal liability for acts undertaken in connection withan incapacitated person’s care or treatment care provided theact is reasonably believed to be in their best interests andany restraint used is proportionate. However, if the patienthas never consented to this procedure, and does not have capacityto do so, we would advise great caution in proceeding with switchingoff the patient’s pacemaker or ICD in these circumstances. Itwould seem appropriate to seek the permission of the courtswhere this situation arises. We suggest that due to the potentialfor the patient to have a reduced quality of life as a resultof the pacemaker being deactivated, and the fact that the terminallyill patient will die of natural causes regardless of a functioningpacemaker, then this action will not be in the patient’s overallbest interests. While it would be a more convincing argumentthat switching off the ICD device is in the patient’s best interests,it would be imperative for the doctor looking after the patientto seek clarification and permission from the courts in thiscircumstance.





Training of health-care staff

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff
Who will deactivate the…

Conclusion

REFERENCES

 

Studies have highlighted a lack of knowledge among doctors about pacemaker and ICD deactivation in terminally ill patients.33,34 They suggest that clinical guidelines and physician education regarding deactivation of these devices is necessary. We would recommend that any training of health-care staff should highlight this issue. In one study 91% of responding physicians stated that if they were assured about the legality of discontinuing ICD therapy, they would be willing to discuss voluntary ICD deactivation with their dying patients.35 Clinicians are wellplaced to proactively discuss this issue with patients eitherwhen the pacemaker or ICD is being inserted, or when the patientpresents for follow-up evaluation.





Who will deactivate the device?

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…
Conclusion

REFERENCES

 

A further issue that may arise is who will actually deactivate the electromechanical device? Device manufacturer representatives and cardiac technicians are frequently relied on to perform device reprogramming or deactivation. Newer pacemaker devices that are magnetically shielded will require the intervention of a cardiac technician in order to deactivate them.36 We suggestthat if deactivation is carried out under the instructions ofa clinician who has obtained and documented the patient’s informedconsent, then ultimately it is the clinician who is responsiblefor the deactivation procedure.





Conclusion

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion
REFERENCES

 

Where a terminally ill patient has a pacemaker or ICD in situand requests that the device is deactivated, it is imperativethat the doctor responsible for the patient’s care informs thepatient of the potential complications of deactivating the device.A failure to obtain fully informed patient consent could potentiallyrender deactivation of the device euthanasia. Similarly, ifthe patient requests that the device be deactivated in the contextof undiagnosed or subclinical depression, this could renderthe procedure physician-assisted suicide.

It is the responsibility of the doctor to decide what treatments are clinically indicated and should be provided to a patient, but this is subject to a competent patient’s consent or, if the patient does not have capacity, case law states that the known views of the patient prior to becoming incapacitated should be considered.37

A patient may refuse a previously consented intervention or request its withdrawal if the patient’s goals have changed or the intervention no longer meets his or her goals.38 Cliniciansshould determine whether patients who request withdrawal oflife-sustaining interventions have decision-making capacityand efforts should be made to reverse depression or any illnessthat may affect capacity. If an advance decision has been made,the patient’s request is consistent with previously expressedvalues and goals, and the patient’s circumstances have not changed,then it should be followed. If the patient has made a validLasting Power of Attorney which clearly states that the doneecan authorize switching off the electromechanical device, thenthis should also be followed.

If the patient does not have capacity to give consent to theirpacemaker or ICD being deactivated, then the doctor responsiblefor the patient’s care should seek permission from the courtsif it is felt there is a pressing clinical need to deactivatethe device. While this will be uncommon in patients with a pacemaker,it is more likely to arise in a patient with an ICD. A proposalto switch off a pacemaker in a terminally ill incapacitatedpatient is unlikely to satisfy the best interest test that thecourt will apply to any decision regarding withdrawal of treatment.This is because there is a substantial risk that the patient’squality of life may be reduced as a result of the pacemakerdevice being deactivated, and also because studies have shownthat pacemaker-dependent patients do not live any longer thantheir non-pacemaker-dependent counterparts; in other words,the patient will die of their terminal illness regardless ofthe pacemaker.

In terminally ill patients who have an ICD in situ the argumentthat deactivating the device is in the patient’s best interestswill be more persuasive to the courts. The potential for increaseddelivery of painful, distressing shocks at the time leadingup to the patient’s death, and the risk of shocks to carersand loved ones mean this situation is distinguishable from thatof pacemakers.

The incorporation of certain provisions of the European Convention on Human Rights into English Law by the Human Rights Act 1998 will also raise important considerations should this issue come before the courts. In particular, Article 2 protects a persons right to life, Article 3 prohibits inhuman and degrading treatment and Article 8 requires respect for a person’s private and family life. The General Medical Council’s (GMC) guidance on withholding and withdrawing life-prolonging treatments notes that these provisions of the Human Rights Act make it likely that a doctor’s decision in relation to withholding or withdrawing treatment are likely to be subject to greater scrutiny and the decision-making process would need to be open, transparent and justifiable.39 The GMC guidance is also clear that doctors are responsible to their patients and society at large, and are individually accountable to the GMC and in the courts for their decision about withholding and withdrawing life-prolonging treatments.40

Most pacemakers are inserted into an expanding population ofolder patients; therefore, this is an issue that is likely toarise with increasing frequency and complexity. Equally, theincidence of clinically detected ventricular tachyarrhythmiascontinues to increase and therefore it is reasonable to assumethat the number of patients with an ICD will also increase.It is therefore imperative that clinicians understand the medicolegalissues which they are faced with when consideration is beinggiven to deactivate these devices. The importance of informedconsent cannot be overstated when this issue is raised.




REFERENCES

TOP

Abstract

Introduction

Assisted suicide, euthanasia and…

Pacemakers

ICD devices

Postmortem

Capacity and consent

Incapacity and no consent

Training of health-care staff

Who will deactivate the…

Conclusion

REFERENCES

 

  1. Christensen SA (2008) Turning Off Your Pacemaker. When Terminal Illness Intervenes, A Cardiac Pacer Can be Deactivated. See http://medicalethics.suite101.com/article.cfm/turning_off_your_pacemaker (last checked December 2009)
  2. Maisel WH, Moynahan M, Zuckerman BD. Pacemaker and ICD generator malfunctions: analysis of Food and Drug Administration annual reports. JAMA 2006;295:1901–6[Abstract/Free Full Text]
  3. Suicide Act 1961, s.1
  4. Suicide Act 1961, s.2
  5. Airedale NHS Trust v Bland [1993] 1 All ER 821 (HL)
  6. R v Cox [1992] 12 BMLR 38
  7. Hooper A, Ormerod D. Blackstone’s Criminal Practice. London: OUP, 2009
  8. Wilner S (2003) Case of the month: comprehensive palliative care program: keeping pace with technology: implantable cardiac devices in palliative care. UPMC Health System. 3(12). See http://www.mcw.edu/display/displayFile.asp?docid2463&filename=/User/jrehm/Case23.pdf (last checked December 2009)
  9. Lewis WR, Leuebke DL, Johnson NJ, Harrington ND, Costantini O, Aulisio NP. Withdrawing implantable defibrillator shock therapy in terminally ill patients. Am J Med 2006;119:892–6[Medline]
  10. Airedale NHS Trust v Bland [1993] 1 All ER 821 (HL)
  11. McQuoid Mason D. Pacemakers and end of life decisions. SAMJ 2005;95:566–7[Medline]
  12. Braun TC, Hagen NA, Hatfield R, et al. Cardiac pacemakers and implantable defibrillators in terminal care. J Pain Symptom Manage 1999;18:126–31[Medline]
  13. Wilner S (2003), supra
  14. Re B [1981] 1 WLR 421; Re R (Adult: Medical Treatment) [1996] 2 FLR 99
  15. Lewis WR, (2006), supra
  16. Sherazi S, Daubert JP, Block RC, et al. Physicians’ preferences and attitudes about end of life care in patients with an implantable cardioverter defibrillator. Mayo Clin Proc 2008;83:1139–41[Abstract/Free Full Text]
  17. Wilner S. (2003), supra
  18. Ibid.
  19. Sherazi S, (2008), supra
  20. Lewis WR, (2006), supra
  21. Silviera MJ. When is deactivation of artificial pacing and AICD illegal, immoral and unethical? Am J Geriatr Cardiol 2003;12:275–6[Medline]
  22. Gottleib SS. Dead as dead — artificial definitions are no substitute. Lancet 1997;349:662–3[Medline]
  23. MDA/2008/068. See http://www.mhra.gov.uk (last checked December 2009)
  24. Yates FD, Orr RD. Is it permissible to shut off this pacemaker? Ethics Med Int J Bio Ethics 2008;24:15–8
  25. Mueller PS, Hook C, Hayes DL. Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clin Proc 2003;78:959–63[Abstract/Free Full Text]
  26. American College of Cardiology Foundation. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol 2008;51:1–62[Abstract/Free Full Text]
  27. Mental Capacity Act 2005, s.1(2)
  28. Mental Capacity Act 2005, s.1(5)
  29. Mental Capacity Act 2005, s.4
  30. Mental Capacity Act 2005, s.4(5)
  31. Mental Capacity Act 2005, s.4(10)
  32. Mental Capacity Act 2005, s.9(1)(a)
  33. Kelley AS, Mehta SS, Reid MC. Management of patients with ICDs at the end of life (EOL): a qualitative study. Am J Hosp Palliat Care 2008;25:440–6[Medline]
  34. Sherazi S, (2008), supra
  35. Ibid.
  36. Christensen SA. (2008), supra
  37. Re G (Persistent Vegetative State) [1995] 2 FCR 46
  38. Mueller PS, (2003), supra
  39. Withholding and withdrawing life-prolonging treatments: good practice in decision-making. GMC (2006). See http://www.gmc-uk.org/guidance/current/library/witholding_lifeprolonging_guidance.asp (last checked December 2009)
  40. Ibid., para 30

Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients
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This Article
Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients

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Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients
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Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients
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Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients

Articles by McGeary, A.

Articles by Eldergill, A.
Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients
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Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients
Medicolegal issues arising when pacemaker and implantable cardioverter defibrillator devices are deactivated in terminally ill patients

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