Implantable cardioverter defibrillators may cause hospice patients unnecessary pain

Patients with implantable cardioverter defibrillators rarely have the devices deactivated upon admission to hospice care — possibly resulting in discomfort due to unnecessary electrical shocks that may cause greater stress and anxiety for family members.

Researchers surveyed a stratified random sample of hospice facilities in nine U.S. census regions. The survey included questions about how frequently patients were admitted with ICDs; the frequency with which these patients received shocks; existence of ICD deactivation policies; and how often these were implemented if they existed.

Among the 441 facilities that responded, 97% reported admitting patients with ICDs, with 58% reporting that a patient had been shocked in the year prior to the survey. Despite these numbers, only 20% of facilities had questions on intake forms to identify patients with these devices, and 10% had ICD deactivation policies in place. Data indicated that on average, clinicians deactivated the shocking function in 42% of patients with ICDs (95% CI, 37%-48%).

“Hospices are the foremost experts at dealing with the complex communication issues surrounding end-of-life discussions with patients and their families,” study researcher Nathan Goldstein, MD, assistant professor at the Hertzberg Palliative Care Institute, Mount Sinai School of Medicine in New York City, said in a press release. “The fact that so few organizations have a policy about deactivation shows how complicated these conversations are. Having a policy in place can improve communication and provide better quality of care for patients and their families.”

Goldstein and colleagues created a sample deactivation policy based on existing programs in the hospices surveyed that has been published along with the original study. The policy outlines steps for identifying ICD devices; informed consent to deactivate the device; and processes for reprogramming ICDs — including in emergent scenarios and postmortem care. The researchers emphasized that this policy has not been pilot-tested and should be implemented only after identifying community partners who can assist with ICD reprogramming. – by Nicole Blazek

Goldstein N. Ann Intern Med. 2010;152:296-299.

End-of-life decisions are among the most difficult we as health care providers must help families make. As death due to ventricular arrhythmias is reduced by ICD therapy, death due to other causes increases. It seems important therefore to put in place guidelines on how to manage ICDs in patients in a hospice environment. That may take a conversation among the hospice team, the arrhythmia team, and the patient and their family. Shocks at the end of life seem to me inappropriate.

– Dan Roden, MD
Cardiology Today Editorial Board

I found it very interesting that most hospices did not have established policies on dealing with ICD patients under their care. Almost all the hospices in the survey had ICD patients and many had patients who had been shocked. A limitation is that the administrators who answered the survey might not have known all the detailed floor level nursing protocols, but still the results were surprising.

Many non-electrophysiologist physicians are uncomfortable dealing with ICD deactivations both because of lack of technical expertise and discomfort with the end-of-life discussion. The latter problem should not really apply to physicians managing patients in a hospice. Fortunately, the Heart Rhythm Society is about to publish guidelines for end-of-life care for device patients and this will be a valuable reference for clinicians.

– John Philip DiMarco, MD, PhD
Cardiology Today Editorial Board

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