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Callaghan EM, Diamandis-Nikoletatos E, van Leeuwen PP, Higgins JB, Somerville CE, Brown LJ, Schumacher TL. Communication regarding the deactivation of implantable cardioverter-defibrillators: A scoping review and narrative summary of current interventions. PATIENT EDUCATION AND COUNSELING 2022; 105:3431-3445. [PMID: 36055906 DOI: 10.1016/j.pec.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Communication about deactivation of implantable cardioverter-defibrillator (ICD) therapy at end-of-life (EoL) is a recognised issue within clinical practice. The aim of this scoping review was to explore and map the current literature in this field, with a focus on papers which implemented interventional studies. METHODS Systematic searches of six major databases were conducted. Citations were included by four researchers according to selection criteria. Key demographic data and prespecified themes in relation to communication of ICD deactivation at EoL were extracted. RESULTS The search found 6197 texts of which 63 were included: 39 quantitative, 14 qualitative and 10 mixed-methods. Surveys were predominantly used to gather data (n = 34), followed by interviews (n = 18) and retrospective reviews of patient records (n = 18). CONCLUSIONS Several key gaps in the literature warrant further research. These include who is responsible for initiating ICD deactivation discussions, how clinicians should initiate and conduct these discussions, when ICD deactivations should be occurring, and family perspectives. Adequately explored themes include patient and clinician knowledge and attitudes regarding ICD deactivation at EoL. PRACTICAL IMPLICATIONS Facilities treating patients with ICDs at EoL should consider ongoing quality improvement projects aimed at clinician education and protocol changes to improve communication surrounding EoL ICD deactivation.
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Affiliation(s)
- Ellen M Callaghan
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Elly Diamandis-Nikoletatos
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Paul P van Leeuwen
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Jack B Higgins
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | | | - Leanne J Brown
- Department of Rural Health, College of Health, Medicine and Wellbeing, University of Newcastle, Tamworth, NSW 2340, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Tracy L Schumacher
- Department of Rural Health, College of Health, Medicine and Wellbeing, University of Newcastle, Tamworth, NSW 2340, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
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Standing H, Thomson RG, Flynn D, Hughes J, Joyce K, Lobban T, Lord S, Matlock DD, McComb JM, Paes P, Wilkinson C, Exley C. 'You can't start a car when there's no petrol left': a qualitative study of patient, family and clinician perspectives on implantable cardioverter defibrillator deactivation. BMJ Open 2021; 11:e048024. [PMID: 34230020 PMCID: PMC8261879 DOI: 10.1136/bmjopen-2020-048024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/21/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To explore the attitudes towards implantable cardioverter defibrillator (ICD) deactivation and initiation of deactivation discussions among patients, relatives and clinicians. DESIGN A multiphase qualitative study consisting of in situ hospital ICD clinic observations, and semistructured interviews of clinicians, patients and relatives. Data were analysed using a constant comparative approach. SETTING One tertiary and two district general hospitals in England. PARTICIPANTS We completed 38 observations of hospital consultations prior to ICD implantation, and 80 interviews with patients, family members and clinicians between 2013 and 2015. Patients were recruited from preimplantation to postdeactivation. Clinicians included cardiologists, cardiac physiologists, heart failure nurses and palliative care professionals. RESULTS Four key themes were identified from the data: the current status of deactivation discussions; patients' perceptions of deactivation; who should take responsibility for deactivation discussions and decisions; and timing of deactivation discussions. We found that although patients and doctors recognised the importance of advance care planning, including ICD deactivation at an early stage in the patient journey, this was often not reflected in practice. The most appropriate clinician to take the lead was thought to be dependent on the context, but could include any appropriately trained member of the healthcare team. It was suggested that deactivation should be raised preimplantation and regularly reviewed. Identification of trigger points postimplantation for deactivation discussions may help ensure that these are timely and inappropriate shocks are avoided. CONCLUSIONS There is a need for early, ongoing and evolving discussion between ICD recipients and clinicians regarding the eventual need for ICD deactivation. The most appropriate clinician to instigate deactivation discussions is likely to vary between patients and models of care. Reminders at key trigger points, and routine discussion of deactivation at implantation and during advance care planning could prevent distressing experiences for both the patient and their family at the end of life.
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Affiliation(s)
- Holly Standing
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Richard G Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Centre for Rehabilitation, Exercise and Sports Science, Teesside University, Middlesbrough, UK
| | - Julian Hughes
- Department of Population and Health Sciences, University of Bristol, Bristol, UK
| | - Kerry Joyce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Stephen Lord
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Dan D Matlock
- School of Medicine, University of Colorado, Denver, Colorado, USA
| | - Janet M McComb
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Freemantle M, Murtagh F. Implantable cardioverter defibrillator devices: when, how and who should discuss deactivation with patients: a systematic literature review. BMJ Support Palliat Care 2021; 12:359-367. [PMID: 33963003 DOI: 10.1136/bmjspcare-2021-002894] [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: 01/13/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICDs) are used to treat life-threatening cardiac arrhythmias and prevent sudden cardiac arrest. As recipients age they may develop greater risk of dying as a result of progressive multimorbidity rather than sudden cardiac death. Defibrillation shocks may prolong an uncomfortable dying process. Deactivation of the defibrillator would prevent this, yet is not always discussed and planned. AIM To systematically review published evidence on ICD deactivation discussions and make recommendations on when, how and who should facilitate effective and patient-centred deactivation discussions. METHODS Using standard systematic review methods, MEDLINE, EMBASE, CINAHL and PsycInfo were searched for studies published in the English language between 2010 and March 2021. Inclusion criteria were studies of adults (≥18 years) and including discussions on ICD deactivation and/or related communication. Included studies were independently reviewed, data extracted, quality assessed and data synthesised using a deductive approach. RESULTS Of the 8893 articles identified, 22 papers met the inclusion criteria. Deductive approach led to identification of five main themes: (1) timing of ICD deactivation discussions, (2) initiation of deactivation discussions, (3) advance directives, (4) barriers to discussions and (5) facilitators of discussions. CONCLUSIONS Despite available guidelines, conversations on device deactivation are not being undertaken consistently. Evidence suggests lack of professional awareness of guidelines and limited training in communication skills. To prevent distress and promote comfortable dying, there needs to be a proactive clinical and policy initiative in the education of both professionals and patients and their relatives about device deactivation.
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Affiliation(s)
- Megan Freemantle
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Gonzalez-Jaramillo V, Sobanski P, Calvache JA, Arenas-Ochoa LF, Franco OH, Hunziker L, Eychmüller S, Maessen M. Unmet device reprogramming needs at the end of life among patients with implantable cardioverter defibrillator: A systematic review and meta-analysis. Palliat Med 2020; 34:1019-1029. [PMID: 32588755 PMCID: PMC7388150 DOI: 10.1177/0269216320929548] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 Use of implantable cardioverter defibrillators is increasingly common. As patients approach the end of life, it is appropriate to deactivate the shock function. AIM To assess the prevalence of implantable cardioverter defibrillator reprogramming to deactivate the shock function at the end of life and the prevalence of advance directives among this population. DESIGN Following a previously established protocol available in PROSPERO, we performed a narrative synthesis of our findings and used the logit transformation method to perform our quantitative synthesis. DATA SOURCES We searched seven bibliographic databases (Embase, Cochrane Central register of controlled Trials, Medline-Ovid, Web-of-Science, Scopus, PsychInfo, and CINAHL) and additional sources until April 2019. RESULTS Of the references we identified, 14 were included. We found a pooled prevalence of implantable cardioverter defibrillator reprogramming at the end of life of 28% (95% confidence interval, 22%-36%) with higher reprogramming rates after the recommendations for managing the device at the end of life were published. Among patients with advance directives, the pooled prevalence of advance directives that explicitly mentioned the device was 1% (95% confidence interval, 1%-3%). CONCLUSIONS The prevalence of implantable cardioverter defibrillator reprogramming and advance directives that explicitly mentioned the device was very low. Study data suggested reprogramming decisions were made very late, after the patient experienced multiple shocks. Patient suffering could be ameliorated if physicians and other healthcare professionals adhere to clinical guidelines for the good management of the device at the end of life and include deactivating the shock function in the discussion that leads to the advance directive.
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Affiliation(s)
| | - Piotr Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Schwyz, Switzerland
| | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia.,Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Oscar H Franco
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Steffen Eychmüller
- University Center for Palliative Care, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maud Maessen
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,University Center for Palliative Care, Inselspital University Hospital Bern, Bern, Switzerland
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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.
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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
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Sullivan MF, Kirkpatrick JN. Palliative cardiovascular care: The right patient at the right time. Clin Cardiol 2020; 43:205-212. [PMID: 31829448 PMCID: PMC7021658 DOI: 10.1002/clc.23307] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/23/2019] [Accepted: 11/08/2019] [Indexed: 01/11/2023] Open
Abstract
In the increasingly complex world of modern medicine, relationship-centered, team-based care is important in geriatric cardiology. Palliative cardiovascular care plays a central role in defining the scope and timing of medical therapies and in coordinating symptom-targeted care in line with patient wishes, values, and preferences. Palliative care addresses advance care planning, symptom relief and caregiver/family support and seeks to ameliorate all forms of suffering, including physical, psychological, and spiritual. Although palliative care grew out of the hospice movement and has traditionally been associated with care at the end of life, the current model acknowledges that palliative care can be delivered concurrent with invasive, life-prolonging interventions. As the population ages, patients with serious cardiovascular disease increasingly suffer from noncardiac, multimorbid conditions and become eligible for interventions that palliate symptoms but also prolong life. Management of implanted cardiac support devices at the end of life, whether rhythm management devices or mechanical circulatory support devices, can involve a host of complexities in decisions to deactivate, timing of deactivation and even the mechanics of deactivation. Studies on palliative care interventions have demonstrated clear improvements in quality of life and are more mixed on life prolongation and cost savings. There is and will remain a dearth of clinicians with specialist palliative care training. Therefore, cardiovascular clinicians have a role to play in provision of practical, "primary" palliative care.
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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.
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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
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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.
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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
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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.
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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
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Dutzmann J, Israel CW. [Device therapy in cardiological palliative care situations]. Herzschrittmacherther Elektrophysiol 2019; 30:204-211. [PMID: 31049654 DOI: 10.1007/s00399-019-0623-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There is considerable uncertainty about the management of patients with cardiac implantable electronic devices (CIEDs) threatened by immediate or medium-term death due to heart failure or other disease, for patients and their relatives as well as for physicians and medical staff. Patients can be afraid that they cannot die as long as pacing persists; medical staff may forget to deactivate shock therapies in an agonal phase or may not know how to do this without a programmer. For optimal handling of CIEDs in a palliative care situation, patients have to be informed that pacemakers or cardiac resynchronization therapy have no life-prolonging effect in this situation but only limit suffering, particularly due to dyspnea. Palliative care physicians must be informed that ICDs can be temporarily deactivated by magnet application, requiring neither a device specialist nor a programmer. Medical staff has to be trained in empathic discussions about CIED deactivation. An optimal setting for this talk may occur if the patient asks about the course and prognosis of his disease or an advance directive, which includes statements about resuscitation. Palliative care physicians have to understand the different functions of a CIED (antibradycardia pacing, resynchronization, antitachycardia pacing, shock therapy) and the deactivation of each of these components to ensure an appropriate decision; otherwise, CIED management at the end of a patient's life may cause suffering and a sense of guilt in relatives and medical staff.
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Affiliation(s)
- Jochen Dutzmann
- Mitteldeutsches Herzzentrum, Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - Carsten W Israel
- Klinik für Innere Medizin - Kardiologie, Diabetologie und Nephrologie, Evangelisches Klinikum Bethel, Bielefeld, Deutschland
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2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm 2018; 15:e73-e189. [DOI: 10.1016/j.hrthm.2017.10.036] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 02/07/2023]
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2018; 138:e272-e391. [PMID: 29084731 DOI: 10.1161/cir.0000000000000549] [Citation(s) in RCA: 249] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - William G Stevenson
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael J Ackerman
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - William J Bryant
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - David J Callans
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne B Curtis
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Barbara J Deal
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Timm Dickfeld
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael E Field
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Gregg C Fonarow
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne M Gillis
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Christopher B Granger
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Stephen C Hammill
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Mark A Hlatky
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - José A Joglar
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - G Neal Kay
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Daniel D Matlock
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Robert J Myerburg
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Richard L Page
- 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. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
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13
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018; 72:e91-e220. [PMID: 29097296 DOI: 10.1016/j.jacc.2017.10.054] [Citation(s) in RCA: 683] [Impact Index Per Article: 113.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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Practical and ethical considerations in the management of pacemaker and implantable cardiac defibrillator devices in terminally ill patients. Proc (Bayl Univ Med Cent) 2017; 30:157-160. [PMID: 28405065 DOI: 10.1080/08998280.2017.11929566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
More than 4.5 million people worldwide live with an implanted pacemaker, including >3 million in the USA alone. Also, >0.8 million people in the USA have an implantable cardioverter defibrillator (ICD). Knowing the principles of managing these devices towards the end of life is important, as the interruption of their function may have serious consequences. This article provides health care providers who are not specialized in cardiac electrophysiology with an introduction to the general principles of management of pacemakers or ICD devices towards the end of life, with a suggested algorithm for approaching this process. Also discussed are pertinent ethical and practical considerations in deciding on and implementing a management strategy for these devices during terminal illnesses.
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15
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Schleifer JW, Shen WK. Implantable Cardioverter-Defibrillator Implantation, Continuation, and Deactivation in Elderly Patients. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0226-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Gelfman LP, Kavalieratos D, Teuteberg WG, Lala A, Goldstein NE. Primary palliative care for heart failure: what is it? How do we implement it? Heart Fail Rev 2017; 22:611-620. [PMID: 28281018 PMCID: PMC5591756 DOI: 10.1007/s10741-017-9604-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Heart failure (HF) is a chronic and progressive illness, which affects a growing number of adults, and is associated with a high morbidity and mortality, as well as significant physical and psychological symptom burden on both patients with HF and their families. Palliative care is the multidisciplinary specialty focused on optimizing quality of life and reducing suffering for patients and families facing serious illness, regardless of prognosis. Palliative care can be delivered as (1) specialist palliative care in which a palliative care specialist with subspecialty palliative care training consults or co-manages patients to address palliative needs alongside clinicians who manage the underlying illness or (2) as primary palliative care in which the primary clinician (such as the internist, cardiologist, cardiology nurse, or HF specialist) caring for the patient with HF provides the essential palliative domains. In this paper, we describe the key domains of primary palliative care for patients with HF and offer some specific ways in which primary palliative care and specialist palliative care can be offered in this population. Although there is little research on HF primary palliative care, primary palliative care in HF offers a key opportunity to ensure that this population receives high-quality palliative care in spite of the growing numbers of patients with HF as well as the limited number of specialist palliative care providers.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA.
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA.
| | - Dio Kavalieratos
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Winifred G Teuteberg
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anuradha Lala
- Divisions of Cardiology and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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17
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Prevalence, predictors, and outcomes of advance directives in implantable cardioverter-defibrillator recipients. Heart Rhythm 2017; 14:830-836. [DOI: 10.1016/j.hrthm.2017.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Indexed: 11/20/2022]
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18
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Advanced directives in patients with an implantable cardioverter-defibrillator: Some progress but a long way to go. Heart Rhythm 2017; 14:837-838. [DOI: 10.1016/j.hrthm.2017.03.002] [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: 02/24/2017] [Indexed: 11/20/2022]
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19
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The ethics of unilateral implantable cardioverter defibrillators and cardiac resynchronization therapy with defibrillator deactivation: patient perspectives. Europace 2016; 19:1343-1348. [DOI: 10.1093/europace/euw227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/28/2016] [Indexed: 11/14/2022] Open
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20
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McIlvennan CK, Swetz KM. Lack of Agreement With What We Think Is Right Does Not Necessarily Equal an Ethical Problem: Respecting Patients' Goals of Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:13-15. [PMID: 27366837 DOI: 10.1080/15265161.2016.1187220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Keith M Swetz
- b University of Alabama School of Medicine and Birmingham Veterans Affairs Medical Center
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21
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22
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Pasalic D, Gazelka HM, Topazian RJ, Buchhalter LC, Ottenberg AL, Webster TL, Swetz KM, Mueller PS. Palliative Care Consultation and Associated End-of-Life Care After Pacemaker or Implantable Cardioverter-Defibrillator Deactivation. Am J Hosp Palliat Care 2015; 33:966-971. [PMID: 26169518 DOI: 10.1177/1049909115595017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The presence of cardiac pacemakers and defibrillators complicates making end-of-life (EOL) medical decisions. Palliative care/medicine consultation (PCMC) may benefit patients and primary providers, but data are lacking. We retrospectively reviewed 150 charts of patients who underwent device deactivation at our tertiary care center (between November 1, 2008, and September 1, 2012), assessing for PCMC and outcomes. Overall, 42% of patients received a PCMC, and 68% of those PCMCs specifically addressed device deactivation. Median survival following deactivation was 2 days, with 42% of deaths occurring within 1 day of deactivation. There was no difference in survival between the groups. The EOL care for patients with implanted cardiac devices is complex, but PCMC may assist with symptom management and clarification of goals of care for such patients.
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Affiliation(s)
- Dario Pasalic
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Rachel J Topazian
- Mayo Clinic Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | | | - Abigale L Ottenberg
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN, USA.,SSH Health, Mission, Legal and Government Affairs, St Louis, MO, USA
| | - Tracy L Webster
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Keith M Swetz
- Mayo Clinic Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Birmingham VA Medical Center, Birmingham, AL, USA
| | - Paul S Mueller
- Mayo Clinic Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN, USA
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23
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Lane DA, Aguinaga L, Blomström-Lundqvist C, Boriani G, Dan GA, Hills MT, Hylek EM, LaHaye SA, Lip GYH, Lobban T, Mandrola J, McCabe PJ, Pedersen SS, Pisters R, Stewart S, Wood K, Potpara TS, Gorenek B, Conti JB, Keegan R, Power S, Hendriks J, Ritter P, Calkins H, Violi F, Hurwitz J. Cardiac tachyarrhythmias and patient values and preferences for their management: the European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2015; 17:1747-69. [PMID: 26108807 DOI: 10.1093/europace/euv233] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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24
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Kramer DB, Matlock DD, Buxton AE, Goldstein NE, Goodwin C, Green AR, Kirkpatrick JN, Knoepke C, Lampert R, Mueller PS, Reynolds MR, Spertus JA, Stevenson LW, Mitchell SL. Implantable Cardioverter-Defibrillator Use in Older Adults: Proceedings of a Hartford Change AGEnts Symposium. Circ Cardiovasc Qual Outcomes 2015; 8:437-46. [PMID: 26038525 DOI: 10.1161/circoutcomes.114.001660] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel B Kramer
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.).
| | - Daniel D Matlock
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Alfred E Buxton
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Nathan E Goldstein
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Carol Goodwin
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Ariel R Green
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - James N Kirkpatrick
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Christopher Knoepke
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Rachel Lampert
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Paul S Mueller
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Matthew R Reynolds
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - John A Spertus
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Lynne W Stevenson
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
| | - Susan L Mitchell
- From the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (D.B.K., A.E.B., S.L.M.); Hebrew Senior Life Institute for Aging Research, Boston, MA (D.B.K., S.L.M.); University of Colorado, CO (D.D.M.); Mt. Sinai School of Medicine, New York (N.E.G.); American Geriatrics Society, New York (C.G.); Johns Hopkins University School of Medicine, Baltimore, MD (A.R.G.); University of Pennsylvania, Philadelphia (J.N.K.); University of Denver, CO (C.K.); Yale University School of Medicine, New Haven, CT (R.L.); Mayo Clinic, Rochester, MN (P.S.M.); Harvard Clinical Research Institute, Boston, MA (M.R.R.); Mid-American Heart Institute, Kansas City, MO (J.A.S.); and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (L.W.S.)
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25
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Lampert R. Discussions around goals of care: An ethical imperative. Trends Cardiovasc Med 2015; 26:44-5. [PMID: 26022729 DOI: 10.1016/j.tcm.2015.04.012] [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: 04/19/2015] [Accepted: 04/20/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Rachel Lampert
- Yale School of Medicine, Section of Cardiovascular Medicine, New Haven, CT.
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26
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Hill L, McIlfatrick S, Taylor BJ, Dixon L, Cole BR, Moser DK, Fitzsimons D. Implantable cardioverter defibrillator (ICD) deactivation discussions: Reality versus recommendations. Eur J Cardiovasc Nurs 2015; 15:20-9. [DOI: 10.1177/1474515115584248] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/02/2015] [Indexed: 01/06/2023]
Affiliation(s)
- Loreena Hill
- Ulster University, Newtownabbey, UK
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
| | - Sonja McIlfatrick
- Ulster University, Newtownabbey, UK
- All Ireland Institute of Hospice and Palliative Care, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin, Ireland
| | | | - Lana Dixon
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
| | - Ben R Cole
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
| | - Debra K Moser
- Ulster University, Newtownabbey, UK
- University of Kentucky, College of Nursing, Lexington, USA
| | - Donna Fitzsimons
- Ulster University, Newtownabbey, UK
- Belfast Health and Social Care Trust, Royal Group of Hospitals, UK
- All Ireland Institute of Hospice and Palliative Care, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin, Ireland
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27
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Hill L, McIlfatrick S, Taylor B, Dixon L, Harbinson M, Fitzsimons D. Patients' perception of implantable cardioverter defibrillator deactivation at the end of life. Palliat Med 2015; 29:310-23. [PMID: 25239128 DOI: 10.1177/0269216314550374] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Individualised care at the end of life requires professional understanding of the patient's perception of implantable cardioverter defibrillator deactivation. AIM The aim was to evaluate the evidence on patients' perception of implantable cardioverter defibrillator deactivation at end of life. DESIGN Systematic narrative review of empirical studies was published during 2008-2014. DATA SOURCES Data were collected from six databases, citations from relevant articles and expert recommendations. RESULTS In all, 18 studies included with collective population of n = 5810. Concept mapping highlighted three themes: (1) Diverse preferences regarding discussion and deactivation. Deactivation was rarely discussed pre-implantation, with some studies demonstrating patients' reluctance to discuss implantable cardioverter defibrillator deactivation at any stage. Two studies found the majority of patients valued such discussions. Diversity was reflected in patients' willingness to deactivate, ranging from 12% (n = 9) in Irish cohort to 79% (n = 195) in Dutch study. (2) Ethical and legal considerations were predominant in Canadian and American literature as patients wanted to contribute but felt the decision should be a doctor's responsibility. Advance directives were uncommon in Europe, and where they existed the implantable cardioverter defibrillator was not mentioned. (3) 'Living in the now' was evident as despite deteriorating symptoms many patients maintained a positive outlook and anticipated surviving more than 10 years. Several studies asserted living longer was more important than quality of life. CONCLUSION Patients regard the implantable cardioverter defibrillator as a complex and solely beneficial device, with little insight regarding its potential impact on a peaceful death. This review confirms the need for professionals to discuss with patients and families implantable cardioverter defibrillator functionality and deactivation at appropriate opportunities.
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Affiliation(s)
- Loreena Hill
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK Belfast Health and Social Care Trust, Belfast, UK
| | - Sonja McIlfatrick
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK All Ireland Institute of Hospice & Palliative Care, Dublin, Ireland
| | - Brian Taylor
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK
| | - Lana Dixon
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - Donna Fitzsimons
- Institute of Nursing Research, University of Ulster, Jordanstown Campus, Newtownabbey, UK Belfast Health and Social Care Trust, Belfast, UK All Ireland Institute of Hospice & Palliative Care, Dublin, Ireland
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28
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Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN. Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:917-24. [PMID: 25683098 DOI: 10.1111/pace.12614] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 01/30/2015] [Accepted: 02/09/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unilateral do-not-resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. We investigated whether electrophysiology practitioners believe medical futility justifies unilateral implantable cardioverter defibrillator (ICD) deactivation. METHODS AND RESULTS Email invitations to take an online survey were sent to 1,894 electrophysiology practitioners. A total of 384 responses were collected (response rate 20.6%). Though the sample included respondents from Europe, Asia, Australia, South America, and Africa, the majority were from North America (78%), were academically affiliated (64%), and practiced in an urban setting (67.8%). Deactivation of ICD shock function in agreement with patient wishes and a preexisting DNR were not considered physician-assisted suicide (93.2%, 358/384). However, a majority of the sample responded that it was not ethical/moral for doctors to deactivate ICDs against patients' wishes (77.1%, 296/384) or against family/surrogates' wishes (72.4%, 278/384), even in the context of medical futility. A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding cardiopulmonary resuscitation or external defibrillation in a code (72.7%, 277/381), but was different than deactivating pacing in a pacemaker-dependent patient (82.8%, 318/384). In the classification of interventions, a plurality (43.0%, 165/383) regarded ICDs to be unlike any other intervention. Concerning pacemakers, 50% (191/382) considered them to be like dialysis (a therapy that keeps patients alive). CONCLUSIONS This international sample of electrophysiology practitioners considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not.
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29
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Chamsi-Pasha H, Chamsi-Pasha MA, Albar MA. Ethical challenges of deactivation of cardiac devices in advanced heart failure. Curr Heart Fail Rep 2015; 11:119-25. [PMID: 24619521 DOI: 10.1007/s11897-014-0194-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.
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Affiliation(s)
- Hassan Chamsi-Pasha
- Head of Non-Invasive Cardiology, Department of Cardiology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia,
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30
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Abstract
BACKGROUND Implantable defibrillators (ICDs) prevent sudden cardiac death. With declining health, ICD therapy may prolong death and expose the patient to unnecessary pain and anxiety. Few studies have addressed end of life care in ICD patients. The objective of this study was to investigate end of life in ICD patients, with respect to location of death; duration between do-not-resuscitate (DNR)-orders and deactivation of ICD therapy or DNR and time of death. METHODS AND RESULTS A descriptive analysis of 65 deceased ICD patients, all whom had a written DNR-order before death, is presented. The majority (86%) was treated in hospitals, mainly (63%) university hospitals, and many (33%) in cardiology wards. Despite DNR-order, ICD shock therapy was active in 51% of all patients. In those with therapy deactivated at death, therapy deactivation was carried out two days or more after DNR-order in more than a third (38%). The time from DNR decision to death in patients with therapy active had a median of four days (IQR 1-38). During the last 24h of life, 24% of the patients experienced shock treatment. CONCLUSIONS The majority of ICD patients with a DNR-order were treated in university hospitals. More than half still had shock treatment active at time of death with a median of four days or more between DNR decision and death. Patients with therapy deactivated, two days or more elapsed in more than a third from DNR decision to deactivation of therapy, exposing patients to a high risk of painful shocks before death.
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Pasalic D, Tajouri TH, Ottenberg AL, Mueller PS. The prevalence and contents of advance directives in patients with pacemakers. Pacing Clin Electrophysiol 2013; 37:473-80. [PMID: 24215172 DOI: 10.1111/pace.12287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/05/2013] [Accepted: 09/02/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the use of advance directives (ADs) in patients who have implantable cardiac pacemakers (PMs). METHODS We conducted a retrospective review of the medical records of residents of Olmsted County, Minnesota, who underwent implantation of a cardiac PM at Mayo Clinic (Rochester, Minnesota) during 2006 and 2007, and determined the prevalence and contents of ADs in these patients. RESULTS During the study period, 205 residents of Olmsted County (men, 53%) underwent PM implantation (mean age [standard deviation] at implantation, 77 [15] years). Overall, 120 patients (59%) had ADs. Of these, 63 ADs (53%) were executed more than 12 months before and 33 (28%) were executed after PM implantation. Many patients specifically mentioned life-prolonging treatments in their ADs: cardiopulmonary resuscitation, 76 (63%); mechanical ventilation, 56 (47%); and hemodialysis, 31 (26%). Pain control was mentioned in 79 ADs (66%) and comfort measures were mentioned in 42 ADs (35%). Furthermore, the AD of many patients contained a general statement about end-of-life care (e.g., no "heroic measures"). However, only one AD (1%) specifically addressed the end-of-life management of the PM. CONCLUSIONS More than half of the patients with PMs in our study had executed an AD, but only one patient specifically mentioned her PM in her AD. These results suggest that patients with PMs should be encouraged to execute ADs and specifically address end-of-life device management in their ADs. Doing so may prevent end-of-life ethical dilemmas related to PM management.
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Affiliation(s)
- Dario Pasalic
- Mayo Medical School, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
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