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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 August 20, 2019 e451 CLINICAL STATEMENTS AND GUIDELINES

pacemakers will prolong the process of death, studies show that many physicians report uneasiness with conversations related to device management at the end of life, with many physicians feeling more uncomfortable deactivating pacemakers than defibrillators.S14-1 Therefore, understanding the legal, ethical, and practical issues related to pacemaker deactivation is imperative. This topic has been addressed extensively in an HRS consensus statement; therefore, only a summary of the most important issues is provided here.S14-2 From the legal and ethical standpoint, a patient with decision-making capacity, or his/her legally defined surrogate, has the right to refuse or request withdrawal of any medical treatment or intervention, including pacemakers, regardless of whether the treatment prolongs life and its withdrawal would result in death. Withdrawal of a life sustaining medical intervention with the informed consent of a patient or legal surrogate should not be considered physician-assisted suicide, and honoring these requests should be considered to be an integral aspect of patient-centered care.S14-3 As with decisions surrounding implantation of pacemakers, these decisions should be undertaken by patients or legally defined surrogate and physicians together using the principles of shared decision-making. Physicians should clarify for patients or their legally defined surrogates and their families the expected consequences of pacemaker deactivation. Patients and their families may wrongly assume that pacemakers may prolong the process of dying and thus prolong suffering. However, in general, pacemakers do not keep dying patients alive, because terminal events are often caused by various of other clinical conditions, such as cancer and, at the time of death, the pacemaker will ultimately fail to capture myocardial muscle rendering it irrelevant. Because pacemaker pulses are painless, in most cases pacemaker deactivation is unnecessary and reassurance of patients and family in addition to turning off cardiac monitoring may be all that is needed. If the decision is made to deactivate a pacemaker, patient death may follow immediately after the cessation of pacing therapy if the patient is completely pacemaker dependent. However, in those who are not pacemaker dependent, the process of death may be unpredictable. It is possible that turning off a pacemaker may lead to additional discomfort; therefore, patients must be monitored closely for potential symptoms, such as respiratory distress, which may require intensification of comfort care measures. Pacemaker deactivation requires a written order from the responsible physician, which should be accompanied by a do-not-resuscitate order as well. Additional documentation in the medical record should include confirmation that the patient (or legal surrogate) has requested device deactivation, capacity of the patient to make the decision or identification of the appropri- ate surrogate and documentation that alternative therapies as well as documentation that the consequences of deactivation have been discussed.S14-2 Palliative care and medical support should be provided to the patient and family in order to provide comfort in view of potential symptoms that may arise. Access to clergy (or chaplain) should be offered and provided according to the patient’s individual religious beliefs. If the clinician asked to deactivate a device has religious or ethical beliefs that prohibit him or her from carrying out device deactivation, he or she should not be forced to do so, and instead the patient should be referred to a different physician who is capable and willing.

Ideally, providers and healthcare systems that care for pacemaker patients should have processes in place for device deactivation when the time comes. Conversation related to end-of-life issues ideally should begin either at the time of device implant, or early during the early stages of the terminal illness. Clinicians should encourage patients undergoing device implantation to complete advanced directives and specifically address the matter of device management and deactivation if the patient is terminally ill.

15 KNOWLEDGE GAPS AND FUTURE

RESEARCH

Gaps in the understanding of the management of bradycardia persist, particularly in the evolving role and developing technology for pacing. His bundle pacing is an emerging area of interest and is particularly relevant in patients who require significant amounts of ventricular pacing, but the long-term outcomes for this approach in large populations of patients remain uncertain.S15-1,S15-2 The role of pacing among patients with transient bradycardia with reflex-mediated syncope beyond those with documented transient asystole is also uncertain.S15-3,S15-4 Although cardiac resynchronization pacing is associated with improvement in outcomes among patients with atrioventricular block and heart failure in general,S15-5,S15-6 the role of cardiac resynchronization in the subgroup of patients with an LVEF of >35% remains incompletely understood. The relative merits of His bundle pacing, cardiac resynchronization, or other pacing strategies for maintaining or improving left ventricular function in patients with atrioventricular block is unknown. In addition, pacing with entirely leadless devices is also an emerging area of interest,S15-7,S15-8 but the role of these new devices in real-world practice, and their potential interaction with other cardiac devices, is not yet clear. Regardless of technology, for the foreseeable future, pacing therapy requires implantation of a medical device and future studies will be required to focus on the long-term implications associated with lifelong therapy.

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