The Specialist: With Great Power Comes Great Responsibility

John Mandrola


January 27, 2015


This is a story about ICDs, but you can substitute heart surgery, chemotherapy, and many other aggressive treatments. The message is the same.

The situation is a common one: an 86-year-old man considers having an ICD revision.

We know about this case because this man—a retired psychiatrist—has two daughters, both physicians, who wrote a poignant Caregiver Viewpoint essay in Circulation Outcomes.[1]

The good thing about bad cases is how much they teach us. That is, if we are strong enough to face our imperfections.

The Case

(My brief editorial comments are in italics.)

His current ICD had a major lead problem, which forced him to make a choice: deactivate the device or have surgery to replace the new lead.

The ICD was first put in 7 years ago for these reasons: (Gulp.)

"A sudden block in the blood flow to his heart damaged the heart muscle and caused ventricular fibrillation. His ICD was implanted emergently, then he later underwent stenting of his blocked artery."

His ICD never delivered therapy. Nor did it pace. For a few years after the initial implant, he lived with well-compensated heart failure. More recently, he had developed an unsteady gate that led to a fall, fractured sacrum, and a small intracranial bleed. (Perhaps you recognize this as frailty.)

His daughters wrote that, as a retired psychiatrist, he could have understood medical nuances. (If they were offered.)

On possible complications of a lead revision, the patient relayed to his daughters: "I had to be careful about my arm for a few days. They plan to watch me overnight."

On whether the option of not doing the procedure was discussed, the patient said, "No. The cardiologist said the ICD would not be reliable without repairing the lead, so he had not hesitated."

On whether he had considered the fact that his ICD had never gone off, the retired doctor said, "I want a working ICD."

The daughters wrote that their father "saw the procedure as a minor one that provided insurance against a potentially fatal event." (The insurance-policy analogy again.)

He had the lead-revision surgery. A pneumothorax extended his hospital stay 4 days. Shortly after discharge, he experienced a series of falls, leg weakness, and another hospital admission. His new lead worked perfectly, but his overall health sank to a lower baseline. (A gain in wellness?)

The daughters then go on to discuss the quality of the medical decision-making. They concede that the lead revision may have been consistent with their dad's wishes but lament the inadequate presentation of the risks, possibility of deactivation, and overall benefit in an elderly patient. (If the patient understood the facts, would he have insisted on a working ICD?)

In an addendum, they wrote that "our father died unexpectedly at home in April 2014."


A steward . . . a person whose responsibility it is take care of something.

In medicine, the first something to take care of is people. But for the specialist in 2015, there are other things that require stewardship as well: decision quality concerning the use of aggressive treatments, especially in the elderly or chronically ill.

As a group of doctors, electrophysiologists are lucky; engineers and other innovators have harnessed technology and gifted us with truly remarkable tools. Implantable defibrillators, for instance, give us the power to extend human life. To a point. And surely not without trade-offs.

That is one side of the decision: ICDs as protectors.

Here is another side: The heart and its rhythm worries people. Maybe not as much as cancer, but it is close. Will the heart suddenly stop? Will it race so fast it quits? "They say I have a scar in my heart. . . . I will do whatever you think is best, doc."

Fear creates a problem in medicine. It gets in the way of rational evidence-based decisions. Fear obscures our view of absolute benefits. Fear causes us to forget the Methods section of clinical trials. Fear favors action. Do something. Fear makes it harder to see that our devices shock people, or worse: lessen the possibility of a good death. Fear might even make us forget that people still die of "natural causes."

Enter the specialist. Electrophysiologists understand things that most people do not. We get the heart rhythm. We know our tools. This knowledge gives us immense power in the doctor-patient (and specialist-referring doctor) relationship. Our job, therefore, entails much more than just skills with a catheter or a pacemaker lead. It means recognizing our power and communicating not only the benefits of our actions, but also the risks, alternatives, and most important, the expectations.

And there is more: We may not want to be involved in something as difficult as end-of-life goals, but ICDs put us there. Decision quality is on us. Indeed, death is a heavy weight.

If I had only one thing to say about ICD decisions, it would be this:

When you add up all the issues, the competing causes of death and the risks of surgery, what is the overall mortality of the patient with the device and what is the overall morality without it?

The problem this patient had was that his specialists—his stewards—did not tell him that his mortality with the device was no different from what it would be without it. It is likely they did not tell him that because it is hard to do so. When you tell a person with competing causes of death that it does little good overall to prevent arrhythmic death, you accept death as a normal part of life. You accept that humans are mortal and that your patient is close. Yes, definitely, that is hard.

Far easier is to say "the ICD would not be reliable without repairing the lead."

If an 86-year-old retired doctor—with two physician daughters—cannot experience decision quality concerning his ICD, there is much work to do in ending the humanitarian crisis in the way we treat the elderly.

Stewards take care of things.



Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: