An ICD, an Endotracheal Tube, and Two Women Who Disagree

Fix the process problems before the content.

• Replace the daughter as interpreter. She is a party to the disagreement; using her risks distortion and puts her in an impossible role. Use a professional Spanish interpreter, in person or by video, and speak directly to the wife.
• Establish who the surrogate is under state law. Absent a written proxy, the default is usually the spouse. Tell the daughter her voice matters and that she is not being sidelined.
• Clarify his own capacity. He is awake, follows commands, and can spell or point to a letter board. If he can express a choice consistently, his voice outranks both women. Ask yes/no questions: 'Are you in pain right now?' 'Are you writing that you want the breathing tube out?'

Structure of the meeting

• Ask what each of them understands and fears before presenting anything.
• Explore values: what has he said about being kept alive by machines, about his mother's death, about what makes life worth living.
• Use a shared agenda and summarize aloud; check understanding with teach-back.
• End with named next steps and a scheduled follow-up meeting, not a vague 'we will keep talking.'

Never let the meeting end with two family members holding contradictory impressions of what was decided.

Ethically and legally. Disabling the defibrillator is withdrawal of a life-sustaining treatment, not assisted dying. Courts and professional societies treat it as the patient's or legitimate surrogate's right, and the device is a treatment that can be refused like any other. This distinction must be stated out loud, because families often hear 'turning off the ICD' as 'killing him.'

Practically

• Arrange a programmer to disable tachytherapy; keeping pacemaker function if he were pacemaker-dependent (he is not).
• Alternatively, a magnet over the device suspends shocks temporarily; know your institution's plan for after-hours requests.
• Document who requested it, who consented, what was disabled, and by whom.
• Ask early rather than in the last hour: shocks in the final weeks of life are common, distressing, and preventable.

If the daughter refuses

• Defer to the patient if he has capacity; otherwise the legal surrogate, usually the wife, decides.
• Do not deactivate without consent from the appropriate decision maker.
• Address the objection: 'What worries you most about turning it off?' Offer a time-limited trial with continued defibrillation, and involve the ethics committee if conflict persists.
• Reassure her that comfort-focused care, including stopping milrinone and extubation if he wishes, does not require her agreement to every step at once.

Write it as a contract with explicit terms.

'Mr. C, with his wife as surrogate (pending confirmation of his own capacity), agrees to a 72-hour trial of milrinone with ongoing mechanical ventilation. The goal is to determine whether he can be liberated from the ventilator and leave the intensive care unit. He will continue to receive analgesia and sedation targeted to comfort.'

Parameters to specify

• A reassessment date and time, with named clinician and attendees.
• Concrete success criteria: diuresis, improving renal function, weaning to pressure support with acceptable gas exchange, ability to participate in decisions.
• Concrete failure criteria agreed in advance: rising creatinine or worsening liver function, escalating vasopressor need, no ventilator weaning progress, new confusion, or his own repeated communication that he wants the tube out.

Then do the hard part

• Tell the family explicitly: 'If these things happen, we will recommend stopping, and here is what that would look like' - extubation if he is comfortable, opioids for air hunger, the ICD discussed, hospice or inpatient comfort care.
• Revisit daily and document at each visit.
• Prespecify the alternative so that the withdrawal conversation on day three is a continuation, not a surprise.