Toward a Less Painful Death: ICD Deactivation at End of LifeOctober 14, 2011
By Sylvia Foley, AJN senior editor
A few years ago, in a letter to the editor of another journal, an NP described how one of her patients, a man on home hospice care, had suffered 33 shocks as he lay dying in his wife’s arms. The source of those shocks, his implantable cardioverter-defibrillator (ICD), reportedly “got so hot that it burned through his skin.” The device that had been implanted to save his life caused this man and his wife great distress in his final hours. Device deactivation at the end of life is an option; but in this case, apparently, it had never been discussed.
Stories like this one helped to inspire the research reported in this month’s CE feature, “Deactivation of ICDs at the End of Life: A Systematic Review of Clinical Practices and Provider and Patient Attitudes,” by James Russo.
ICDs, standard treatment for people at risk for life-threatening cardiac arrhythmias, work to restore normal rhythm by delivering a high-energy, painful electrical shock. The devices are so effective that people with ICDs often die from causes other than heart disease. But once a person with an ICD begins actively dying, as in the case above, the device may cause needless pain and prolonged suffering. So it’s essential for providers and patients to talk about the possibility of deactivation, well in advance of such crises.
Russo, the coordinator of the pacemaker clinic at the Department of Veterans Affairs Medical Center in New York City, wanted to better understand why providers and patients weren’t discussing this possibility and to find ways to promote more timely discussions. To that end, he conducted a systematic review of the literature published between 1999 and 2010. He identified 14 studies investigating the topics of interest; in this article, he reports on and discusses his findings.
Among the most notable:
- Deactivation discussions are uncommon. When they do occur, most take place in the last hours or days of a patient’s life.
- Provider attitudes play a role in delaying such discussions. Providers have reported personal discomfort with the subject, inadequate knowledge of device functions, and time constraints that prevent strong provider-patient rapport
- There is scant research on patient attitudes about ICD deactivation. One study found that patients “seemed unaware that a range of reprogramming options might exist,” indicating that patients lack adequate knowledge to make informed decisions.
Russo offers recommendations on how nurses can incorporate ICD deactivation discussions into the plan of care and provides examples of questions for starting such conversations. For more, read the article online (it’s free), and don’t miss our podcast interview with Russo. The article has been sparking widespread interest on the Web as well, in venues as varied as MSNBC and the Consumer Justice Foundation. It’s an encouraging sign; the more people begin to talk about this issue, the more likely it is that change will occur. Your thoughts?