VANCOUVER, B.C. - People with implanted cardioverter defibrillators should be given the option of having the devices deactivated when they enter hospice care, Dr. Bernard Lee told his audience at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.
When avoidance of sudden death is no longer the goal, deactivation of the devices to prevent shocking patients as their hearts fail "is ethically the right thing to do," said Dr. Lee, associate chief medical officer of hospice and palliative care at the Metropolitan Jewish Health System in Brooklyn, N.Y.
Although the issue has gotten some attention in recent years, research has shown that fewer than half of implanted cardioverter defibrillators (ICDs) are deactivated in hospice patients, said Dr. Lee (Ann. Intern. Med. 2010;152:296-9).
"We are not really doing a good job," said Dr. Michael Mencias, also of Metropolitan Jewish Health System. Even if the patient is unconscious and can’t feel the painful jolts, his or her body will jerk with each shock, alarming family members and making them feel that they didn’t make the patient’s final hours as comfortable as possible.
Often, patients and families – sometimes even providers – don’t know that ICDs can be painlessly deactivated magnetically and that doing so may prevent havoc at the end of life. And not infrequently, families have the mistaken impression that deactivation equals euthanasia or physician-assisted suicide, said Dr. Lee and Dr. Mencias.
Pacing Function Left Active
Palliative care and hospice clinicians can do better, the speakers said. A position statement from the National Organization of Hospice and Palliative Care gives tips on how to handle the issue (www.nhpco.org/files/public/NHPCO_ICD_position_statement_May08.pdf). In short, the group recommends asking all patients or families at hospice admission (or as soon as possible) whether a defibrillator has been implanted.
The group says that a health professional should then explain the potential problems if an ICD is not deactivated, and that deactivation is not likely to hasten death. When a patient has decided whether to keep the device turned on, everyone on the medical team should be so informed, says the statement.
The ICD’s detection of ventricular tachycardia or fibrillation – the function that tells the device to fire – can be deactivated either by a manufacturer’s technician or (less permanently) by a medical professional who can secure a magnet over the device. Available from ICD makers, the magnets are strong and measure a few inches across. They deactivate the sensing function, but that function returns if the magnet is removed.
When a patient’s time is short, Dr. Lee said he tries to quickly pull together a family meeting to discuss deactivation. "In worst-case scenarios, it’s done over the phone with the hospice physician and the patient or health care surrogate," he added.
For hospice patients at home, a magnet can be left with the family, with instructions on how to tape it to the chest to stop body-jolting shocks. Home-visiting nurses in Dr. Lee’s organization carry magnets in their cars in case a patient who is dying at home needs one quickly.
The application of magnets to a patient’s chest, however, is "certainly not a long-term solution for somebody who’s not actively dying," Dr. Lee said. Especially for frail patients who have lost weight, a magnet taped to the chest is uncomfortable, he added.
Deactivation Hesitation
Dr. Lee said that his organization broaches the topic of deactivation within 5 days of a patient’s admission to hospice. If the person opts for deactivation, the device’s manufacturer is called.
Often patients will have lost the card that came with their ICD, said Dr. Lee, so it’s necessary to call the various manufacturers – typically Medtronics, Guidant/Boston Scientific, and St. Jude Medical – to find out what device the patient carries. The companies will have a record.
Technicians will make house calls, if necessary, to deactivate an ICD’s sensing function in the presence of a licensed medical professional, and they can return to reactivate it if the patient changes his or her mind.
Deactivation usually requires a hospice physician’s order, said Dr. Lee. "Most physicians in the community are not comfortable writing that order."
Technicians themselves may even hesitate to deactivate an ICD. "Some of them are uncomfortable, so they will hand you the laptop and say ‘here, click on deactivate.’ We end up doing it," Dr. Mencias said.
Dr. Lee and Dr. Mencias said they have no conflict of interest.