51
|
Alhajaj G, Atkinson J, Keezer MR, Nikolic A, Myers KA. A proposed guideline for vagus nerve stimulator handling in palliative care and after death. Epilepsia 2020; 61:1336-1340. [PMID: 32463125 DOI: 10.1111/epi.16553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/27/2022]
Abstract
Vagus nerve stimulation (VNS) is often used for patients with drug-resistant epilepsy. Although this intervention may improve seizure control and mood, a number of factors must be considered when patients with VNS near end of life. We reviewed relevant literature to create a proposed guideline for management of patients with VNS in palliative care and after death. VNS has multiple possible side effects, including cough and swallowing difficulties. For patients with neurologic disease in palliative care, such adverse effects can severely affect quality of life and increase the risk for complications such as aspiration pneumonia. Patients with VNS should be screened regularly for such side effects, and VNS parameters should be adjusted if they are identified. If a patient requires urgent cardiac resuscitation involving external defibrillation, the VNS should be interrogated immediately afterwards to evaluate its function. During defibrillation, paddles should be placed perpendicular to the VNS, and as far as possible away from it. The VNS can be acutely turned off by taping the magnet to the patient's chest, thereby preventing any possible interference with restoration of a normal heart rhythm. After death, any staff involved with handling the body should be notified that a VNS is in place. The device must be removed prior to cremation, as it can explode with high heat. If the cause of death is unclear, a full postmortem examination should be undertaken, per sudden unexpected death in epilepsy guidelines. If there is concern about device malfunction, the device should be returned to the manufacturer for evaluation.
Collapse
Affiliation(s)
- Ghadd Alhajaj
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jeffrey Atkinson
- Department of Neurology and Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Mark R Keezer
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada.,Research Centre of the University of Montreal Hospital Centre, Montreal, QC, Canada.,Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada
| | - Ana Nikolic
- Clark Smith Brain Tumour Centre, Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kenneth A Myers
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Medical Centre, Montreal, QC, Canada
| |
Collapse
|
52
|
Steiner JM, Kirkpatrick J. Palliative care in cardiology: knowing our patients’ values and responding to their needs. Heart 2020; 106:1693-1699. [DOI: 10.1136/heartjnl-2019-316365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
|
53
|
Turner S, Torabi S, Stilos K. Quality dying: An approach to ICD deactivation in the hospital setting. Am J Hosp Palliat Care 2020; 37:664-668. [PMID: 32126793 DOI: 10.1177/1049909120905254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In Canada, cardiovascular disease is the second most common cause of death. A subset of these patients will require a cardiovascular implantable electronic device (CIED). An estimated 200 000 Canadians are living with a CIED. CIEDs can improve life and prevent premature death. However, when patients reach the end of their lives, they can pose a challenge. An example of which is a painful shock delivered from an implantable cardioverter defibrillator (ICD) for an arrhythmia in a dying patient. Receiving a shock at the end of life (EOL) is unacceptable in an age when we aim to ease the suffering of the dying and allow for a comfortable death. METHODS As a quality standard of practice, all clinicians are expected to engage in EOL conversations in patients requiring CIED deactivation. Due to the potential discomfort of an ICD shock, specific conversations about deactivation of an ICD are encouraged. A process improvement approach was developed by our hospital that included an advance care planning simulation lab, electronic documentation and a standardized comfort measures order set that includes addressing the need for ICD deactivation at EOL. RESULTS EOL conversations are complex. Health care providers have been equally challenged to have conversations about ICD deactivation. Standardization of the process of ICD deactivation ensures an approach to EOL which respects the individuality of patients and promotes quality dying. CONCLUSION Our hospital is committed to assisting clinicians to provide quality care by improving conversations about EOL care. On the basis of a synthesis of existing literature, we describe the importance of and the ideal process for having EOL conversations in patients about ICD deactivation at the EOL.
Collapse
Affiliation(s)
- Suzette Turner
- Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.,Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada
| | - Sarah Torabi
- Division of Palliative Care, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kalli Stilos
- Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada.,Division of Palliative Care, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
54
|
Nakagawa S, Ando M, Takayama H, Takeda K, Garan AR, Yuill L, Rosen A, Topkara VK, Yuzefpolskaya M, Colombo PC, Naka Y, Blinderman CD. Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution. J Palliat Med 2020; 23:368-374. [DOI: 10.1089/jpm.2019.0322] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Shunichi Nakagawa
- Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Masahiko Ando
- Division of Cardiothoracic Surgery, Department of Surgery, Tokyo University, Tokyo, Japan
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Arthur R. Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Lauren Yuill
- Adult Palliative Care, Department of Care Coordination and Social Work, NewYork Presbyterian Hospital, New York, New York
| | - Amanda Rosen
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C. Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Craig D. Blinderman
- Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York
| |
Collapse
|
55
|
Abstract
BACKGROUND Advance care planning and palliative care are gaining recognition as critical care components for adults with CHD, yet these often do not occur. Study objectives were to evaluate ACHD providers' 1) comfort managing patients' physical symptoms and psychosocial needs and 2) perspectives on the decision/timing of advance care planning initiation and palliative care referral. METHODS Cross-sectional study of ACHD providers. Six hypothetical patients were described in case format, followed by questions regarding provider comfort managing symptoms, initiating advance care planning, and palliative care referral. RESULTS Fifty providers (72% physicians) completed surveys. Participants reported low levels of personal palliative care knowledge, without variation by gender, years in practice, or prior palliative care training. Providers appeared more comfortable managing physical symptoms and discussing prognosis than addressing psychosocial needs. Providers recognised advance directives as important, although the percentage who would initiate advance care planning ranged from 18 to 67% and referral to palliative care from 14 to 32%. Barriers and facilitators to discussing advance care planning with patients were identified. Over 20% indicated that advance care planning and end-of-life discussions are best initiated with the development of at least one life-threatening complication/hospitalisation. CONCLUSIONS Providers noted high value in advance directives yet were themselves less likely to initiate advance care planning or refer to palliative care. This raises the critical questions of when, how, and by whom discussion of these important matters should be initiated and how best to support ACHD providers in these endeavours.
Collapse
|
56
|
Affiliation(s)
- Yakup Kilic
- Royal London Hospital, Barts Health National Health Service Trust, London, United Kingdom
- Address for correspondence: Dr. Yakup Kilic, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London E1 1FR, United Kingdom.
| | - Aiman Smer
- Department of Cardiology, Catholic Health Initiative (CHI) Health Creighton University School of Medicine, Omaha, Nebraska
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, and James J. Peters Veterans Affairs Medical Center, Bronx, New York
| |
Collapse
|
57
|
Choi DY, Wagner MP, Yum B, Jannat-Khah DP, Mazique DC, Crossman DJ, Lee JI. Improving implantable cardioverter defibrillator deactivation discussions in admitted patients made DNR and comfort care. BMJ Open Qual 2020; 8:e000730. [PMID: 31922034 PMCID: PMC6937107 DOI: 10.1136/bmjoq-2019-000730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 10/10/2019] [Accepted: 11/20/2019] [Indexed: 11/29/2022] Open
Abstract
Background Unintended shocks from implantable cardioverter defibrillators (ICDs) are often distressing to patients and family members, particularly at the end of life. Unfortunately, a large proportion of ICDs remain active at the time of death among do not resuscitate (DNR) and comfort care patients. Methods We designed standardised teaching sessions for providers and implemented a novel decision tool in the electronic medical record (EMR) to improve the frequency of discussions surrounding ICD deactivation over a 6-month period. The intended population was patients on inpatient medicine and cardiology services made DNR and/or comfort care. These rates were compared with retrospective data from 6 months prior to our interventions. Results After our interventions, the rates of discussions regarding deactivation of ICDs improved from 50% to 93% in comfort care patients and from 32% to 70% in DNR patients. The rates of deactivated ICDs improved from 45% to 73% in comfort care patients and from 29% to 40% in DNR patients. Conclusion Standardised education of healthcare providers and decision support tools and reminders in the EMR system are effective ways to increase awareness, discussion and deactivation of ICDs in comfort care and DNR patients.
Collapse
Affiliation(s)
- Daniel Y Choi
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Michael P Wagner
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Brian Yum
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Deanna Pereira Jannat-Khah
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Derek C Mazique
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Daniel J Crossman
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Jennifer I Lee
- Joan and Sanford I, Weill Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| |
Collapse
|
58
|
Pilkington BC. Treating or Killing? The Divergent Moral Implications of Cardiac Device Deactivation. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 45:28-41. [DOI: 10.1093/jmp/jhz031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
In this article, I argue that there is a moral difference between deactivating an implantable cardioverter defibrillator (ICD) and turning off a cardiac pacemaker (CP). It is, at least in most cases, morally permissible to deactivate an ICD. It is not, at least in most cases, morally permissible to turn off a pacemaker in a fully or significantly pacemaker-dependent patient. After describing the relevant medical technologies—pacemakers and ICDs—I continue with contrasting perspectives on the issue of deactivation from practitioners involved with these devices: physicians, nurses, and allied professionals. Next, I offer a few possible analyses of the situation, relying on recent work in medical ethics. Considerations of intention, responsibility, and replacement support my distinguishing between ICDs and CPs. I conclude by recommending a change in policy of one of the leading cardiac societies.
Collapse
|
59
|
Patient and Professional Factors That Impact the Perceived Likelihood and Confidence of Healthcare Professionals to Discuss Implantable Cardioverter Defibrillator Deactivation in Advanced Heart Failure: Results From an International Factorial Survey. J Cardiovasc Nurs 2019; 33:527-535. [PMID: 29727378 PMCID: PMC6200367 DOI: 10.1097/jcn.0000000000000500] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental digital content is available in the text. Background: Rate of implantable cardioverter defibrillator (ICD) implantations is increasing in patients with advanced heart failure. Despite clear guideline recommendations, discussions addressing deactivation occur infrequently. Aim: The aim of this article is to explore patient and professional factors that impact perceived likelihood and confidence of healthcare professionals to discuss ICD deactivation. Methods and Results: Between 2015 and 2016, an international sample of 262 healthcare professionals (65% nursing, 24% medical) completed an online factorial survey, encompassing a demographic questionnaire and clinical vignettes. Each vignette had 9 randomly manipulated and embedded patient-related factors, considered as independent variables, providing 1572 unique vignettes for analysis. These factors were determined through synthesis of a systematic literature review, a retrospective case note review, and a qualitative exploratory study. Results showed that most healthcare professionals agreed that deactivation discussions should be initiated by a cardiologist (95%, n = 255) or a specialist nurse (81%, n = 215). In terms of experience, 84% of cardiologists (n = 53) but only 30% of nurses (n = 50) had previously been involved in a deactivation decision. Healthcare professionals valued patient involvement in deactivation decisions; however, only 50% (n = 130) actively involved family members. Five of 9 clinical factors were associated with an increased likelihood to discuss deactivation including advanced age, severe heart failure, presence of malignancy, receipt of multiple ICD shocks, and more than 3 hospital admissions during the previous year. Furthermore, nationality and discipline significantly influenced likelihood and confidence in decision making. Conclusions: Guidelines recommend that healthcare professionals discuss ICD deactivation; however, practice is suboptimal with multifactorial factors impacting on decision making. The role and responsibility of nurses in discussing deactivation require clarity and improvement.
Collapse
|
60
|
Thompson JH, Thylén I, Moser DK. Shared Decision-Making About End-of-Life Care Scenarios Compared Among Implantable Cardioverter Defibrillator Patients: A National Cohort Study. Circ Heart Fail 2019; 12:e005619. [PMID: 31601115 DOI: 10.1161/circheartfailure.118.005619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Authors of expert guidelines and consensus statements recommend that decisions at the end-of-life (EOL) be discussed before and after implantation of an implantable cardioverter defibrillator (ICD) and include promotion of shared decision-making. The purpose of this study was to describe experiences, attitudes, and knowledge about the ICD at EOL in ICD recipients and to compare experiences, attitudes, and knowledge in ICD recipients with and without heart failure (HF). We further sought to determine factors associated with having discussions about EOL. METHODS AND RESULTS Using a national registry in Sweden of all ICD recipients (n=5355) in 2012, an EOL questionnaire, along with other ICD-related measures, was completed by 2403 ICD recipients. Of the participants, 1275 (n=53%) had HF. Their responses in the knowledge, experience, and attitude domains were almost identical to those without HF. Forty percent of patients with and without HF did not want to discuss their illness trajectory or deactivation of their ICD ever. In logistic regression analyses, we found that having had an ICD shock (OR, 2.05; CI, 1.64-2.56), having high levels of anxiety (OR, 1.41; CI, 1.04-1.92), and having high levels of ICD concerns (OR, 1.53; CI, 1.22-1.92) were the only significant predictors of having discussions with providers about EOL scenarios (P<0.001 for full model). CONCLUSIONS HF was not a predictor of having an EOL conversation. Further research is needed to determine if attitudes related to not wanting to discuss EOL interfere with good quality of life and of death, or if shared decision-making should be encouraged in these individuals.
Collapse
Affiliation(s)
| | - Ingela Thylén
- Departments of Cardiology and Medical and Health Sciences, Linköping University, Sweden (I.T.)
| | - Debra K Moser
- College of Nursing, University of Kentucky, Lexington (J.H.T., D.K.M.)
| |
Collapse
|
61
|
Goldstein NE, Mather H, McKendrick K, Gelfman LP, Hutchinson MD, Lampert R, Lipman HI, Matlock DD, Strand JJ, Swetz KM, Kalman J, Kutner JS, Pinney S, Morrison RS. Improving Communication in Heart Failure Patient Care. J Am Coll Cardiol 2019; 74:1682-1692. [PMID: 31558252 PMCID: PMC7000126 DOI: 10.1016/j.jacc.2019.07.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. OBJECTIVES The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. METHODS In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. RESULTS A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. SECONDARY OUTCOMES Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. CONCLUSIONS The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).
Collapse
Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, Arizona
| | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, New Jersey; Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Jacob J Strand
- Division of General Internal Medicine, Department of Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, Alabama
| | - Jill Kalman
- Lenox Hill Hospital, Northwell Health, New York, New York
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sean Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| |
Collapse
|
62
|
Training, Triggers, and a Team for the Right Discussions. J Am Coll Cardiol 2019; 74:1693-1696. [DOI: 10.1016/j.jacc.2019.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 11/21/2022]
|
63
|
Trussler A, Alexander B, Campbell D, Alhammad N, Enriquez A, Chacko S, Garrett T, Simpson C, Redfearn D, Abdollah H, Herx L, Baranchuk A. Deactivation of Implantable Cardioverter Defibrillator in Patients With Terminal Diagnoses. Am J Cardiol 2019; 124:1064-1068. [PMID: 31353003 DOI: 10.1016/j.amjcard.2019.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 11/29/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death. However, in patients with terminal illnesses, these devices may disrupt the dying process. This study was undertaken to review our current strategies surrounding device deactivation. A retrospective chart review was performed at Kingston Health Sciences Centre of patients with an ICD who died from 2015 to 2018. Data collected included patient demographics, clinical details surrounding device implantation, patient co-morbidities leading to deactivation, time to deactivation, physical place of deactivation, and device programming information. Ethics approval was obtained from the Queen's University Health Sciences Research Ethics Board. A total of 49 patients were included for analysis. Mean age at the time of death was 77.5 years (range: 57 to 94 years) and 12.2% (6/49) were women. The indications for ICD implantation were primary prevention of sudden cardiac death in 69.4% (34/49) and secondary prevention in 30.6% (15/49). Deactivation as part of end-of-life care was performed in 32.7% of patients (16/49). Deactivations occurred in clinic in 6.1% (3/49) of patients, on hospital inpatient wards in 12.2% (6/49) of patients, and in critical care settings in 14.2% (7/49) of patients. The remaining 67.3% (33/49) of patients died with fully functioning devices in place. The most prevalent terminal diagnoses were metastatic cancer (22.4%) and end-stage congestive heart failure (20.4%). On average, patients had their devices deactivated 13 months (range: 0 to 62 months) after their terminal diagnosis was established. Once a patient was documented as Do Not Resuscitate (DNR), deactivation was discussed and carried out within a mean time of 38 days (range: 0 to 400 days). Seven patients had their device active for more than 1 month after being documented as DNR. Ten patients (20.4%) received ICD shocks after their terminal diagnosis, 9 received shocks in the month before death, and 2 received shocks after formal DNR orders were in place. Approximately one-third of patients with ICDs received deactivation of their cardioversion/defibrillation therapies as part of their end-of-life care plan. A relatively high proportion of patients (20%) received an ICD shock in the last month of life. In conclusion, addressing device programming needs, including deactivation of cardioversion/defibrillation therapies, should be considered in the context of a patient's goals of care in every patient with an ICD who has a co-existing life-limiting diagnosis.
Collapse
Affiliation(s)
- Alexander Trussler
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Bryce Alexander
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Debra Campbell
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Nasser Alhammad
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Andrés Enriquez
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Sanoj Chacko
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Timothy Garrett
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Chris Simpson
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Damian Redfearn
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Hoshiar Abdollah
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Leonie Herx
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada.
| |
Collapse
|
64
|
Stoevelaar R, Brinkman-Stoppelenburg A, van Driel AG, van Bruchem-Visser RL, Theuns DA, Bhagwandien RE, Van der Heide A, Rietjens JA. Implantable cardioverter defibrillator deactivation and advance care planning: a focus group study. Heart 2019; 106:190-195. [PMID: 31537636 PMCID: PMC6993024 DOI: 10.1136/heartjnl-2019-315721] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Implantable cardioverter defibrillators can treat life-threatening arrhythmias, but may negatively influence the last phase of life if not deactivated. Advance care planning conversations can prepare patients for future decision-making about implantable cardioverter defibrillator deactivation. This study aimed at gaining insight in the experiences of patients with advance care planning conversations about implantable cardioverter defibrillator deactivation. Methods In this qualitative study, we held five focus groups with 41 patients in total. Focus groups were audio-recorded and transcribed. Transcripts were analysed thematically, using the constant comparative method, whereby themes emerging from the data are compared with previously emerged themes. Results Most patients could imagine deciding to have their implantable cardioverter defibrillator deactivated, for instance because the benefits of an active device no longer outweigh the harm of unwanted shocks, when having another life-limiting illness, or when relatives would think this would be in their best interest. Some patients expressed a need for advance care planning conversations with a healthcare professional about deactivation, but few had had these. Others did not, saying they solely focused on living. Some patients were hesitant to record their preferences about deactivation in advance care directives, because they were unsure whether their current preferences would reflect future preferences. Conclusions Although patients expressed a need for more information, advance care planning conversations about implantable cardioverter defibrillator deactivation seemed to be uncommon. Deactivation should be more frequently addressed by healthcare professionals, tailored to the disease stage of the patient and readiness to discuss this topic.
Collapse
Affiliation(s)
- Rik Stoevelaar
- Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Anne Geert van Driel
- Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands.,Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
65
|
Kinch Westerdahl A, Magnsjö J, Frykman V. Deactivation of implantable defibrillators at end of life - Can we do better? Int J Cardiol 2019; 291:57-62. [PMID: 30853295 DOI: 10.1016/j.ijcard.2019.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/11/2019] [Accepted: 03/01/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dying patients with implantable defibrillators (ICD) have a risk of receiving unnecessary shocks before death. The aim of this study was to investigate if deactivation of shock therapy at end-of-life has increased since publication of new guidelines in 2010 on ICD management. METHOD AND RESULTS This is a study of two groups of ICD patients who died in hospitals before and after publication of new guidelines. Group 1 consists of 89 patients who died between 2003 and 2010. Group 2 consists of 252 patients, the total number of ICD patients in Sweden who died in hospital during 2014. Data was obtained from the Swedish ICD and Pacemaker Registry, Swedish Tax Agency and patient medical notes. Two-thirds died in wards other than Cardiology. Fifty-four percent in group 1 had a Do-Not-Resuscitate-order (DNR) compared to 73% in group 2. Shock deactivation was present in 52% in group 1 and 67% in group 2. The difference in shock deactivation between group 1 and 2 was only significant (p = 0.014) for DNR-patients treated in Cardiology. A significant difference (p = 0.036) was found in deactivation within group 2 between DNR-patients in Cardiology vs. DNR-patients in Non-Cardiology wards. CONCLUSION Two-thirds of ICD patients die in wards other than Cardiology. Since publication of guidelines on ICD management there is a general increase in shock deactivation for DNR-patients, but only significant for patients in Cardiology. This implicate that actions have to be taken for patients treated in Non-Cardiology wards to bridge the gap between guidelines recommendations and clinical practice.
Collapse
Affiliation(s)
| | - Jackline Magnsjö
- Department of Clinical Sciences, Karolinska Institutet, Danderyds Hospital, Sweden
| | - Viveka Frykman
- Department of Clinical Sciences, Karolinska Institutet, Danderyds Hospital, Sweden
| |
Collapse
|
66
|
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm 2019; 16:e128-e226. [DOI: 10.1016/j.hrthm.2018.10.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/13/2022]
|
67
|
Steffen MM, Osborn JS, Cutler MJ. Cardiac Implantable Electronic Device Therapy: Permanent Pacemakers, Implantable Cardioverter Defibrillators, and Cardiac Resynchronization Devices. Med Clin North Am 2019; 103:931-943. [PMID: 31378335 DOI: 10.1016/j.mcna.2019.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cardiac implantable electronic devices (CIEDs) provide lifesaving therapy for the treatment of bradyarrhythmias, ventricular tachyarrhythmias, and advanced systolic heart failure. Advances in CIED therapy have expanded the number of patients receiving permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy devices. These devices improve quality of life and, in many cases, reduce mortality. However, limitations remain in the management of patients who require CIED therapy. This article provides a broad overview of CIED therapy in the management of the cardiac patient.
Collapse
Affiliation(s)
- Melanie M Steffen
- Intermountain Heart Rhythm Specialist, Intermountain Medical Center, 5169 Cottonwood Street, Suite 510, Murray, UT 84107, USA
| | - Jeffery S Osborn
- Intermountain Heart Rhythm Specialist, Intermountain Medical Center, 5169 Cottonwood Street, Suite 510, Murray, UT 84107, USA
| | - Michael J Cutler
- Intermountain Heart Rhythm Specialist, Intermountain Medical Center, 5169 Cottonwood Street, Suite 510, Murray, UT 84107, USA.
| |
Collapse
|
68
|
Sobanski PZ, Alt-Epping B, Currow DC, Goodlin SJ, Grodzicki T, Hogg K, Janssen DJA, Johnson MJ, Krajnik M, Leget C, Martínez-Sellés M, Moroni M, Mueller PS, Ryder M, Simon ST, Stowe E, Larkin PJ. Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement. Cardiovasc Res 2019; 116:12-27. [DOI: 10.1093/cvr/cvz200] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 04/19/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Abstract
Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
Collapse
Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Waldeggstrasse 10, 6430 Schwyz, Switzerland
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Medical Center Göttingen Georg August University, Robertkochstrasse 40, 37075 Göttingen, Germany
| | - David C Currow
- University of Technology Sydney, Broadway, Ultimo, Sydney, 2007 New South Wales, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Sydney, New South Wales, Australia
| | - Sarah J Goodlin
- Department of Medicine-Geriatrics, Portland Veterans Affairs Medical Center and Patient-cantered Education and Research, 3710 SW US Veterans Rd, Portland, 97239 OR, USA
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, 31-531 Kraków, Śniadeckich 10, Poland
| | | | - Daisy J A Janssen
- Department of Research and Education, CIRO, Hornerheide 1, 6085 NM Horn, The Netherlands
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Allam Medical Building University of Hull, Cottingham Road, Hull, HU6 7RX, UK
| | - Małgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Carlo Leget
- University of Humanistic Studies, Chair Care Ethics, Kromme Nieuwegracht 29, Utrecht, The Netherlands
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Matteo Moroni
- S.S.D. Cure Palliative, sede di Ravenna, AUSL Romagna, Via De Gasperi 8, 48121 Ravenna, Italy
| | - Paul S Mueller
- Mayo Clinic Health System, Mayo Clinic Collage of Medicine and Science, 700 West Avennue South, La Crosse, 54601 Wisconsin, USA
| | - Mary Ryder
- School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland St. Vincent’s University Hospital Dublin,Belfield, Dublin 4, Ireland
| | - Steffen T Simon
- Department of Palliative Medicine, Medical Faculty of the Universityof Cologne, Köln, Germany
- Centre for Integrated Oncology Cologne/Bonn (CIO), Medical Faculty ofthe University of Cologne, Kerpener Strasse 62, 50924 Köln, Germany
| | | | - Philip J Larkin
- Service des soins palliatifs Lausanne University Hospital, CHUV, Centre hospitalier univeritaire vaudois, Lausanne Switzerland
- Institut universitaire de formation et de recherche en soins – IUFRS, Faculté de viologie et de medicine – FBM, Lausanne, Switzerland
| |
Collapse
|
69
|
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2019; 140:e382-e482. [DOI: 10.1161/cir.0000000000000628] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Kenneth A. Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- ACC/AHA Representative
| | - Michael R. Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
| | | | | | - José A. Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N. Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
- Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
| | | | | | | |
Collapse
|
70
|
DeFilippis EM, Nakagawa S, Maurer MS, Topkara VK. Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions. J Am Geriatr Soc 2019; 67:2410-2419. [DOI: 10.1111/jgs.16105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Ersilia M. DeFilippis
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Shunichi Nakagawa
- Adult Palliative Care, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine Columbia University College of Physicians and Surgeons New York New York
| |
Collapse
|
71
|
Oken K, Schoenfeld MH, Kusumoto F. Evaluation and Treatment of Patients With Bradycardia and Cardiac Conduction Delay. JAMA Cardiol 2019; 4:823-824. [DOI: 10.1001/jamacardio.2019.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Keith Oken
- Department of Cardiovascular disease, Mayo Clinic, Jacksonville, Florida
| | - Mark H. Schoenfeld
- Division of Cardiology, Department of Medicine, Yale University, New Haven, Connecticut
| | - Fred Kusumoto
- Department of Cardiovascular disease, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|
72
|
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. J Am Coll Cardiol 2019; 74:e51-e156. [DOI: 10.1016/j.jacc.2018.10.044] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
73
|
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary. J Am Coll Cardiol 2019; 74:932-987. [DOI: 10.1016/j.jacc.2018.10.043] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
74
|
Tischer T, Bebersdorf A, Albrecht C, Manhart J, Büttner A, Öner A, Safak E, Ince H, Ortak J, Caglayan E. Deactivation of cardiovascular implantable electronic devices in patients nearing end of life : Reality or only recommendation? Herz 2019; 45:123-129. [PMID: 31312871 DOI: 10.1007/s00059-019-4836-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/23/2019] [Accepted: 06/21/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Current guidelines recommend considering deactivation of cardiac implantable electronic devices (CIEDs) in patients nearing death. We evaluated the implementation of this recommendation in unselected deceased individuals with CIEDs. METHODS Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for CIEDs and these were interrogated in situ. Pacing rate, pacing mode, and lead output were documented as well as patient data including location and time of death. In implantable cardioverter-defibrillators (ICDs), tachycardia therapy adjustment and occurrence of shocks 24 h prior to death were also recorded. RESULTS We examined 2297 subjects, of whom 154 (6.7%) had CIEDs. Of these subjects, 125 (100%) pacemakers (PMs) and 27 (96.4%) ICDs were eligible for analysis. Death in persons with ICDs occurred most frequently in hospital (55.6%), while this was less frequently the case for individuals with PMs (43.2%). Furthermore, 33.3% of subjects with ICDs and 18.5% with PMs died in palliative care units (PCU). Shock therapies were switched off in three (60%) individuals with ICDs who died in the PCU, whereas antibradycardia therapy was not withdrawn in any PM patient in the PCU. Therapy withdrawal occurred in two patients with PMs (1.3%) who died in hospital. Patients with PMs had high ventricular pacing rates at the last interrogation (69 ± 36.0%) and often suffered atrioventricular block (39.2%). Six (25%) of the 24 active ICDs presented shocks near the time of death. CONCLUSION Many CIED patients died in hospital; nonetheless, in practice, CIED deactivation near death is rarely performed and might be less feasible in subjects with PMs. However, there is still a need to consider deactivation, especially in individuals with ICDs, as one fourth of them received at least one shock within 24 h prior to death.
Collapse
Affiliation(s)
- T Tischer
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
| | - A Bebersdorf
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - C Albrecht
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - J Manhart
- Institute of Legal Medicine, Rostock University Medical Center, Rostock, Germany
| | - A Büttner
- Institute of Legal Medicine, Rostock University Medical Center, Rostock, Germany
| | - A Öner
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - E Safak
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Berlin, Germany
| | - H Ince
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - J Ortak
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Berlin, Germany
| | - E Caglayan
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| |
Collapse
|
75
|
Evaluating and managing bradycardia. Trends Cardiovasc Med 2019; 30:265-272. [PMID: 31311698 DOI: 10.1016/j.tcm.2019.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 11/22/2022]
Abstract
Bradycardia is a commonly observed arrhythmia and a frequent occasion for cardiac consultation. Defined as a heart rate of less than 50-60 bpm, bradycardia can be observed as a normal phenomenon in young athletic individuals, and in patients as part of normal aging or disease (Table 1). Pathology that produces bradycardia may occur within the sinus node, atrioventricular (AV) nodal tissue, and the specialized His-Purkinje conduction system. Given the overlap of heart rate ranges with non-pathologic changes, assessment of symptoms is a critical component in the evaluation and management of bradycardia. Treatment should rarely be prescribed solely on the basis of a heart rate lower than an arbitrary cutoff or a pause above certain duration. In the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay (referred to hereafter as the 2018 Bradycardia Guideline), there was a significant shift in emphasis from prior guidelines that emphasized device-based implantation recommendations to a focus on evaluation and management of disease states [1,2]. In this review, we will highlight the changes in the new guideline as well as describe the key elements in evaluation and management of patients presenting with bradycardia.
Collapse
|
76
|
Withholding or withdrawing life support versus physician-assisted death: a distinction with a difference? Curr Opin Anaesthesiol 2019; 32:184-189. [PMID: 30817393 DOI: 10.1097/aco.0000000000000686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Withholding or withdrawing life-sustaining therapy is generally differentiated from physician-assisted suicide or euthanasia based on the distinction between intention and foresight. We reviewed the literature surrounding the validity of this distinction. RECENT FINDINGS Many physicians from different specialties express a perceived distinction between intention and foresight. The distinction between intention and foresight differs from the morally irrelevant distinction between doing and allowing. Intention and foresight may be distinguished by their opposing directions of fit between world and mind. Intention is held to be of greater moral significance than foresight because it guides and constrains our actions, determines the moral quality of our actions, and expresses the moral character of the agent. Opponents of the distinction argue that it undermines moral accountability for foreseen consequences of our actions and is overly concerned with the physician's state of mind rather than the patient's experience. They also argue that intentions may be vague and difficult to express or ascertain. SUMMARY Several reasons may be given in favor of the distinction between intention and foresight. Given this distinction, the moral permissibility of withholding or withdrawing life-sustaining therapy does not necessarily entail the moral permissibility of physician-assisted suicide or euthanasia.
Collapse
|
77
|
Doporučení pro deaktivaci implantabilních kardioverterů- -defibrilátorů u pacientů v terminální fázi života.Společný dokument odborných společností: České kardiologické společnosti, z.s.; České společnosti paliativní medicíny ČLS JEP; České gerontologické a geriatrické společnosti ČLS JEP. COR ET VASA 2019. [DOI: 10.33678/cor.2019.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
78
|
Kramer DB, Buxton AE, Zimetbaum PJ. Facilitating Conversion of Implantable Cardioverter-Defibrillator Therapy to Pacing Only-Time to Adapt. JAMA Cardiol 2019; 4:401-402. [PMID: 30994859 DOI: 10.1001/jamacardio.2019.0882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel B Kramer
- The Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alfred E Buxton
- The Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Peter J Zimetbaum
- The Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
79
|
Stoevelaar R, Brinkman-Stoppelenburg A, van Driel AG, Theuns DA, Bhagwandien RE, van Bruchem-Visser RL, Lokker IE, van der Heide A, Rietjens JA. Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records. Eur J Cardiovasc Nurs 2019; 18:449-457. [PMID: 30995145 PMCID: PMC6661715 DOI: 10.1177/1474515119844660] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The implantable cardioverter defibrillator (ICD) might give unwanted shocks in the last month of life. Guidelines recommend deactivation of the ICD prior to death. AIMS The aims of this study were to examine trends in time (2007-2016) in how and when decisions are made about ICD deactivation, and to examine patient- and disease-related factors which may have influenced these decisions. In addition, care and ICD shock frequency in the last month of life of ICD patients are described. METHODS Medical records of a sample of deceased patients who had their ICD implanted in 1999-2015 in a Dutch university (n = 308) or general (n = 72) hospital were examined. RESULTS Median age at death was 71 years, and 88% were male. ICD deactivation discussions increased from 6% for patients who had died between 2007 and 2009 to 35% for patients who had died between 2013 and 2016. ICD deactivation rates increased in these periods from 16% to 42%. Presence of do-not-resuscitate (DNR) orders increased from 9% to 46%. Palliative care consultations increased from 0% to 9%. When the ICD remained active, shocks were reported for 7% of patients in the last month of life. Predictors of ICD deactivation were the occurrence of ICD deactivation discussions after implantation (OR 69.30, CI 26.45-181.59), DNR order (OR 6.83, CI 4.19-11.12), do-not-intubate order (OR 6.41, CI 3.75-10.96), and palliative care consultations (OR 8.67, CI 2.76-27.21). CONCLUSION ICD deactivation discussions and deactivation rates have increased since 2007. Nevertheless, ICDs remain active in the majority of patients at the end of life, some of whom experience shocks.
Collapse
Affiliation(s)
- Rik Stoevelaar
- 1 Department of Public Health, Erasmus University Medical Center Rotterdam, The Netherlands
| | | | - Anne Geert van Driel
- 2 Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands.,3 Rotterdam University of Applied Sciences, The Netherlands
| | - Dominic Amj Theuns
- 4 Department of Cardiology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Rohit E Bhagwandien
- 4 Department of Cardiology, Erasmus University Medical Center Rotterdam, The Netherlands
| | | | - Ineke E Lokker
- 6 Department of Quality and Patient Care, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Agnes van der Heide
- 1 Department of Public Health, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- 1 Department of Public Health, Erasmus University Medical Center Rotterdam, The Netherlands
| |
Collapse
|
80
|
Mooney M, McKee G, McDermott E, O'Donnell S, Ryan P, Moser D, O'Brien F. Patients' knowledge and opinions of ICDs during life, illness and at the time of death. ACTA ACUST UNITED AC 2019; 28:446-451. [DOI: 10.12968/bjon.2019.28.7.446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mary Mooney
- Assistant Professor and Lecturer, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Gabrielle McKee
- Professor, Biological Sciences, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | | | - Sharon O'Donnell
- Assistant Professor and Lecturer, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Paul Ryan
- Chief Cardiac Physiologist, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Debra Moser
- Professor and Gill Endowed Chair, University of Kentucky, College of Nursing, Lexington, KY, USA
| | - Frances O'Brien
- Assistant Professor and Lecturer, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| |
Collapse
|
81
|
Cavanagh CE, Rosman L, Lampert R, Chui PW, Johnston ML, Burg MM. Planning ahead: End-of-life decisions for patients with defibrillators. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:548-552. [PMID: 30779352 DOI: 10.1111/pace.13641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/13/2018] [Accepted: 02/13/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Casey E Cavanagh
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Pain, Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lindsey Rosman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Pain, Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Rachel Lampert
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Philip W Chui
- Pain, Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Matthew M Burg
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
82
|
Chugh SS, Aro AL, Reinier K. The Conundrum of Defibrillators in the Elderly. J Am Coll Cardiol 2019; 69:275-277. [PMID: 28104070 DOI: 10.1016/j.jacc.2016.10.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Sumeet S Chugh
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Aapo L Aro
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kyndaron Reinier
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
83
|
Abstract
Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.
Collapse
|
84
|
Fowler LH. Nursing Management for Patients Postoperative Cardiac Implantable Electronic Device Placement. Crit Care Nurs Clin North Am 2018; 31:65-76. [PMID: 30736936 DOI: 10.1016/j.cnc.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
As cardiac implantable electronic devices (CIEDs) continue to evolve and patients continue to live longer, the use of these devices increases. CIEDs include permanent pacemakers, implanted cardioverter-defibrillators, and cardiac resynchronization therapy devices. Over the last 2 decades, the functionality of these devices has increased and can be complex. Critical care nurses should be equipped with the knowledge to care for patients immediately postoperative CIED placement and for patients admitted to critical care units with CIEDs already in place. Patients with CIEDs are a vulnerable population with special needs and considerations for management.
Collapse
Affiliation(s)
- Leanne H Fowler
- LSU Health New Orleans School of Nursing, 1900 Gravier Street, New Orleans, LA 70112, USA.
| |
Collapse
|
85
|
Khera R, Pandey A, Link MS, Sulistio MS. Managing Implantable Cardioverter-Defibrillators at End-of-Life: Practical Challenges and Care Considerations. Am J Med Sci 2018; 357:143-150. [PMID: 30665495 DOI: 10.1016/j.amjms.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 01/11/2023]
Abstract
Implantable cardioverter-defibrillators (ICDs) monitor for and terminate malignant arrhythmias. Given their potential as a life-saving therapy, an increasing number of people receive an ICD every year, and a growing number are currently living with ICDs. However, cardiopulmonary arrest serves as the final common pathway of natural death, and the appropriate management of an ICD near the end-of-life is crucial to ensure that a patient's death is not marked by further suffering due to ICD shocks. The tenets of palliative care at the end-of-life include addressing any medical intervention that may preclude dying with dignity; thus, management of ICDs during this phase is necessary. Internists are at the forefront of discussions about end-of-life care, and are likely to find discussions about ICD care at the end-of-life particularly challenging. The present review addresses issues pertaining to ICDs near the end of a patient's life and their potential impact on dying patients and their families. A multidisciplinary, patient-centered approach can ensure that patients receive the maximum benefit from ICDs, without any unintended pain or suffering.
Collapse
Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark S Link
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Melanie S Sulistio
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
| |
Collapse
|
86
|
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Heart Rhythm 2018; 16:e227-e279. [PMID: 30412777 DOI: 10.1016/j.hrthm.2018.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/22/2022]
|
87
|
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation 2018; 140:e333-e381. [PMID: 30586771 DOI: 10.1161/cir.0000000000000627] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | | | - Kenneth A Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.,ACC/AHA Representative
| | - Michael R Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.,HRS Representative
| | | | | | - José A Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.,HRS Representative.,Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
| | | | | | | |
Collapse
|
88
|
Thylén I, Moser DK, Strömberg A. Octo- and nonagenarians' outlook on life and death when living with an implantable cardioverter defibrillator: a cross-sectional study. BMC Geriatr 2018; 18:250. [PMID: 30342484 PMCID: PMC6195969 DOI: 10.1186/s12877-018-0942-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 10/10/2018] [Indexed: 12/16/2022] Open
Abstract
Background Elderly individuals are increasingly represented among patients with implantable cardioverter defibrillators (ICD), but data describing life with an ICD are scarse among octo- and nonagenarians. Moreover, few studies have reported those elderly patients’ perspective on timly discussions concerning what shock deactivation involves, preferences on battery replacement, and their attitudes about turning off the ICD nearing end-of-life. Consequently, the aim of the study was to describe outlooks on life and death in octo- and nonagenarian ICD-recipients. Methods Participants were identified via the Swedish Pacemaker- and ICD-registry, with 229 octo- and nonagenarians (82.0 ± 2.2 years, 12% female) completing the survey on one occasion. The survey involved questions on health and psychological measures, as well as on experiences, attitudes and knowledge of end-of-life issues in relation to the ICD. Results The majority (53%) reported their existing health as being good/very good and rated their health status as 67 ± 18 on the EuroQol Visual Analog Scale. A total of 34% had experienced shock(s), 11% suffered from symptoms of depression, 15% had anxiety, and 26% reported concerns related to their ICD. About one third (34%) had discussed their illness trajectory with their physician, with those octo- and nonagenarians being more decisive about a future deactivation (67% vs. 43%, p < .01). A minority (13%) had discussed what turning off shocks would involve with their physician, and just 7% had told their family their wishes about a possible deactivation in the future. The majority desired battery replacement even if they had reached a very advanced age when one was needed (69%), or were seriously ill with a life-threatening disease (55%). When asked about deactivation in an anticipated terminal illness, about one third (34%) stated that they wanted to keep the shocks in the ICD during these circumstances. About one-fourth of the octo- and nonagenarians had insufficient knowledge regarding the ethical aspects, function of the ICD, and practical consequences of withdrawing the ICD treatment in the end-of-life. Conclusions Increasing numbers of elderly persons receive an ICD and geriatric care must involve assessments of life expectancy as well as the patient’s knowledge and attitudes in relation to generator changes and deactivation.
Collapse
Affiliation(s)
- Ingela Thylén
- Department of Cardiology and Department of Medical and Health Sciences, Division of Nursing Sciences, Linköping University, S-581 83, Linköping, Sweden.
| | - Debra K Moser
- College of Nursing, University of Kentucky, Lexington, USA
| | - Anna Strömberg
- Department of Cardiology and Department of Medical and Health Sciences, Division of Nursing Sciences, Linköping University, S-581 83, Linköping, Sweden.,Sue and Bill Gross School of Nursing, University of California, Irvine, USA
| |
Collapse
|
89
|
Educating Nurses About End-of-Life Care for Patients With Implanted Cardioverter Defibrillators. J Hosp Palliat Nurs 2018; 20:459-463. [PMID: 30188439 DOI: 10.1097/njh.0000000000000462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Many people with implanted cardioverter defibrillators (ICDs) are living at home and receiving nursing services through home health care agencies. Near the end of life, it is not unusual for patients to request comfort measures and care that promotes quality rather than quantity of life. The purpose of this pilot study was twofold: (1) to educate home health care nurses on care of patients with ICDs nearing the end of life and (2) to measure changes in nurse knowledge pre to post educational session. None of the registered nurses in this study reported ever caring for a patient who had died with an ICD in place. Subsequently, their knowledge in end-of-life care surrounding this patient population significantly improved after the educational session (P < .006). Knowing how to care for such patients as they are dying is imperative for nurses, especially because many ICD recipients have insufficient knowledge themselves and can benefit from education provided by nurses.
Collapse
|
90
|
User-centered Development of a Decision Aid for Patients Facing Implantable Cardioverter-Defibrillator Replacement. J Cardiovasc Nurs 2018; 33:481-491. [DOI: 10.1097/jcn.0000000000000477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
91
|
Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies. Pediatr Crit Care Med 2018; 19:S10-S18. [PMID: 30080802 DOI: 10.1097/pcc.0000000000001488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
As part of the invited supplement on Death and Dying in the PICU, we reviewed ethical, cultural, and social considerations for the bedside healthcare practitioner prior to engaging with children and families in decisions about limiting therapies, withholding, or withdrawing therapies in a PICU. Clarifying beliefs and values is a necessary prerequisite to approaching these conversations. Striving for medical consensus is important. Discussion, reflection, and ethical analysis may determine a range of views that may reasonably be respected if professional disagreements persist. Parental decisional support is recommended and should incorporate their information needs, perceptions of medical uncertainty, child's condition, and their role as a parent. Child's involvement in decision making should be considered, but may not be possible. Culturally attuned care requires early examination of cultural perspectives before misunderstandings or disagreements occur. Societal influences may affect expectations and exploration of such may help frame discussions. Hospital readiness for support of social media campaigns is recommended. Consensus with family on goals of care is ideal as it addresses all parties' moral stance and diminishes the risk for superseding one group's value judgments over another. Engaging additional supportive services early can aid with understanding or resolving disagreement. There is wide variation globally in ethical permissibility, cultural, and societal influences that impact the clinician, child, and parents. Thoughtful consideration to these issues when approaching decisions about limitation or withdrawal of life-sustaining therapies will help to reduce emotional, spiritual, and ethical burdens, minimize misunderstanding for all involved, and maximize high-quality care delivery.
Collapse
|
92
|
Incorporating patients' preference diagnosis in implantable cardioverter defibrillator decision-making: a review of recent literature. Curr Opin Cardiol 2018; 33:42-49. [PMID: 29216014 DOI: 10.1097/hco.0000000000000464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Strong recommendations exist for implantable cardioverter defibrillators (ICD) in appropriately selected patients. Yet, patient preferences are not often incorporated when decisions about ICD therapy are made. Literature published since 2016 was reviewed aiming to discuss current advances and ongoing challenges with ICD decision-making in adults, discuss shared decision-making (SDM) as a strategy to incorporate preference diagnoses, summarize current evidence on effective interventions to facilitate SDM, and identify opportunities for research and practice. RECENT FINDINGS Advances in risk stratification can identify patients who will most and least likely benefit from the ICD. Interventions to support SDM are emerging. These interventions present options, the risks, and the benefits of each option, and elicit patients' values and preferences regarding possible outcomes. SUMMARY Appropriate patient selection for initial or continued ICD therapy is multifactorial. It requires accurate clinical diagnosis using careful risk stratification and accurate preference diagnosis based upon the patient's preferences. SDM aims to unite the elements that constitute these two equally important diagnoses. High-quality decision-making will be difficult to achieve if patients lack or misunderstand information, and if evolving patient preferences are not incorporated when making decisions.
Collapse
|
93
|
Pedersen SS, Knudsen C, Dilling K, Sandgaard NCF, Johansen JB. Living with an implantable cardioverter defibrillator: patients' preferences and needs for information provision and care options. Europace 2018; 19:983-990. [PMID: 27267553 DOI: 10.1093/europace/euw109] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/24/2016] [Indexed: 11/14/2022] Open
Abstract
Aims The clinical management and care of patients with an implantable cardioverter defibrillator (ICD) has shifted from face-to-face in-clinic visits to remote monitoring. Reduced interactions between patients and healthcare professionals may impede patients' transition to adapting post-implant. We examined patients' needs and preferences for information provision and care options and overall satisfaction with treatment. Methods and results Patients implanted with a first-time ICD or defibrillator with cardiac resynchronization therapy (n = 389) within the last 2 years at Odense University Hospital were asked to complete a purpose-designed and standardized set of questionnaires. The level of satisfaction with information provision was high; only 13.1% were dissatisfied. Psychological support for patients (39.9%), their relatives (43.1%), and deactivation of the ICD towards end of life (47.8%) were among the top five topics that patients reported to have received no information about. The top five care options that patients had missed were talking to the same healthcare professional (75.2%), receiving ongoing feedback via remote monitoring (61.1%), having a personal conversation with a staff member 2-3 weeks post-implant (59.6%), having an exercise tolerance test (52.5%), and staff asking how patients felt while hospitalized (50.4%). Patients with a secondary prevention indication and cardiac arrest survivors had specific needs, including a wish for a psychological consult post-discharge. Conclusion Despite a high satisfaction level with information provision, particular topics are not broached with patients (e.g. device activation) and patients have unmet needs that are not met in current clinical practice.
Collapse
Affiliation(s)
- Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Campusvej 55, DK-5230 Odense M, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Charlotte Knudsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Karen Dilling
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | | |
Collapse
|
94
|
Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Gorenek B, Marin F, Dagres N, Ozcan EE, Lenarczyk R, Crijns HJ, Guo Y, Proietti M, Sticherling C, Huang D, Daubert JP, Pokorney SD, Cabrera Ortega M, Chin A. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2018; 21:7-8. [DOI: 10.1093/europace/euy110] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - James M Beattie
- Cicely Saunders Institute, King’s College London, London, UK
| | | | | | - Gheorghe-Andrei Dan
- Cardiology Department, University of Medicine and Pharmacy “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice; Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Vincenzo L Malavasi
- Cardiology Division, Department of Nephrologic, Cardiac, Vascular Diseases, Azienda ospedaliero-Universitaria di Modena, Modena, Italy
| | - Jacques Mansourati
- University Hospital of Brest and University of Western Brittany, Brest, France
| | - Lluis Mont
- Arrhythmia Section, Cardiovascular Clínical Institute, Hospital Clinic, Universitat Barcelona, Barcelona, Spain
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Harry J Crijns
- Cardiology Maastricht UMC+ and Cardiovascular Research Institute Maastricht, Netherlands
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | | | - Dejia Huang
- Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University, Durham, NC, USA
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Boyeros, La Havana Cuba
| | - Ashley Chin
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
| | | |
Collapse
|
95
|
Fahlberg B. Deactivating ICDs at end of life. Nursing 2018; 48:11-12. [PMID: 29794622 DOI: 10.1097/01.nurse.0000532756.41495.bf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Beth Fahlberg
- Beth Fahlberg is the founder and CEO of the Palliative Network, Madison, Wis
| |
Collapse
|
96
|
Stoevelaar R, Brinkman-Stoppelenburg A, Bhagwandien RE, van Bruchem-Visser RL, Theuns DA, van der Heide A, Rietjens JA. The incidence and impact of implantable cardioverter defibrillator shocks in the last phase of life: An integrated review. Eur J Cardiovasc Nurs 2018; 17:477-485. [PMID: 29772911 PMCID: PMC6071218 DOI: 10.1177/1474515118777421] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although the implantable cardioverter defibrillator is successful in terminating life threatening arrhythmias, it might give unwanted shocks in the last phase of life if not deactivated in a timely manner. AIMS This integrated review aimed to provide an overview of studies reporting on implantable cardioverter defibrillator shock incidence and impact in the last phase of life. METHODS AND RESULTS We systematically searched five electronic databases. Studies reporting on the incidence and/or impact of implantable cardioverter defibrillator shocks in the last month of life were included. Fifteen studies were included. Two American studies published in 1996 and 1998 reported on the incidence of shocks in patients who died non-suddenly: incidences were 24% and 33%, respectively, in the last 24 hours, and 7% and 14%, respectively, in the last hour of life. Six American studies and one Danish study published between 1991-1999 reported on patients dying suddenly: incidences were 41% and 68% in the last 24 hours and 22-66% in the last hour. Four American studies and two Swedish studies published between 2004-2015 did not distinguish the cause of death: incidences were 17-32% in the last month, 3-32% in the last 24 hours, and 8% and 31% in the last hour of life. Three American studies published between 2004-2011 reported that shocks in dying patients are painful and distressing for patients, and distressing for relatives and professional caregivers. CONCLUSION If the implantable cardioverter defibrillator is not deactivated in a timely manner, a potentially significant proportion of implantable cardioverter defibrillator patients experience painful and distressing shocks in their last phase of life.
Collapse
Affiliation(s)
- Rik Stoevelaar
- 1 Department of Public Health, University Medical Center Rotterdam, The Netherlands
| | | | - Rohit E Bhagwandien
- 2 Department of Cardiology, University Medical Center Rotterdam, The Netherlands
| | | | - Dominic Amj Theuns
- 2 Department of Cardiology, University Medical Center Rotterdam, The Netherlands
| | - Agnes van der Heide
- 1 Department of Public Health, University Medical Center Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- 1 Department of Public Health, University Medical Center Rotterdam, The Netherlands
| |
Collapse
|
97
|
Javaid MR, Squirrell S, Farooqi F. Improving rates of implantable cardioverter defibrillator deactivation in end-of-life care. BMJ Open Qual 2018; 7:e000254. [PMID: 29713689 PMCID: PMC5922560 DOI: 10.1136/bmjoq-2017-000254] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 03/07/2018] [Accepted: 04/05/2018] [Indexed: 11/06/2022] Open
Abstract
Implantable cardioverter defibrillators (ICDs) save lives in selected patients at risk of sudden cardiac death. However, in patents suffering with terminal illness, ICD therapy could pose a risk of unnecessary futile shocks which could lead to undignified discomfort in their final days of life. National guidelines advise that patients approaching the end of their natural life should be offered a compassionate choice of having their defibrillator deactivated. Following an actual clinical incident involving a patient receiving avoidable ICD shocks in his final hours, we identified shortcomings in communication and gaps in knowledge about ICD management in end-of-life care. We developed a quality improvement programme targeting training and educational support to general physicians and nurses at our large District General Hospital. A series of interventions were delivered including Grand Round presentation, departmental seminars and publicity posters. In parallel, we introduced a local protocol for implementing ICD deactivation which was published on our intranet for Trust-wide accessibility. Following interventions, we examined the clinical notes of each end-of-life care patient who died with an ICD in situ over a 6-month observation period and recorded the proportion who received consent-guided ICD deactivation versus died with an active ICD in situ because no deactivation discussion had been offered. Before our interventions in 2015, 0 out of 10 eligible patients (0%) received consent-guided ICD deactivation. Six months into our campaign to encourage healthcare workers to undertake advance care planning discussion in 2016, 7 out of 13 eligible patients (54%) received consent-guided ICD deactivation and no patients received shocks in their final month of life. This programme was successful in raising awareness of this emerging issue, improving physician knowledge and delivering patient choice as well as contributing to safe and compassionate end-of-life care.
Collapse
Affiliation(s)
- M R Javaid
- Barking, Havering & Redbridge (BHR) NHS Trust, Queen's Hospital, Romford, UK
| | - Suzanne Squirrell
- Barking, Havering & Redbridge (BHR) NHS Trust, Queen's Hospital, Romford, UK
| | - Fahad Farooqi
- Barking, Havering & Redbridge (BHR) NHS Trust, Queen's Hospital, Romford, UK
| |
Collapse
|
98
|
New Dimensions in Palliative Care Cardiology. Can J Cardiol 2018; 34:914-924. [PMID: 29960618 DOI: 10.1016/j.cjca.2018.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 12/19/2022] Open
Abstract
The landscape of patient care at the beginning of the 19th century was dramatically different than it is today. With few good treatment options, illness courses were generally brief. Near the end of life, patients were attended to by spiritual advisors, not health care professionals. Death typically occurred at home, surrounded by friends and family. Moving to the present time, decades of medical advances have significantly improved life expectancy. Cardiology has particularly benefited from many of these advances. Cardiac patients are initiated on optimal medication regimens. As disease burdens progress, interventions such as implantable defibrillators and cardiac resynchronization pacing systems become options for many patients. With further clinical deterioration, select patients might be candidates for ventricular assist devices and heart transplants. These advances have unquestionably improved the prognosis with advanced cardiovascular illnesses. However, they have also changed patient and family attitudes about death and dying, to the point where we have effectively "medicalized our mortality." The importance of introducing palliative care to the cardiac patient population is now well recognized, with the major cardiovascular societies incorporating palliative care principles into their guideline and consensus statement documents. However, despite this recognition, few cardiac patients get access to palliative care and other resources such as hospice. In this article the existing literature on this topic is reviewed and opportunities for developing and fostering a more collaborative relationship between the disciplines of cardiology and palliative care are discussed.
Collapse
|
99
|
|
100
|
Stazi F. End-of-life of implantable defibrillator: are we certain it should always be replaced? J Cardiovasc Med (Hagerstown) 2018. [PMID: 29538158 DOI: 10.2459/jcm.0000000000000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Filippo Stazi
- Cardiology Unit, San Giovanni-Addolorata Hospital, Rome, Italy
| |
Collapse
|