Management of cardiac implantable electronic devices in patients receiving palliative care
- Ann C Garlitski, MD, FACC, FHRS
Ann C Garlitski, MD, FACC, FHRS
- Assistant Professor of Medicine
- Hofstra North Shore-LIJ School of Medicine
- Hofstra University
Discontinuation of cardiac implantable electronic device (CIED) therapy, which encompasses both pacemakers and defibrillators, is a complicated issue. For many patients, these are life-sustaining therapies. In 2010, the Heart Rhythm Society (HRS) released an expert consensus statement on the management of CIEDs in patients nearing the end of life or requesting withdrawal of therapy . This statement outlines the ethical, legal, and religious principles that underlie the decision-making process to withdraw CIEDs.
The issues related to changes in CIED therapy, including specific issues related to palliative care, will be discussed here. Additional discussion of the ethical issues involved in palliative care is presented separately. (See "Ethical issues in palliative care".)
FREQUENCY OF LATE-LIFE ICD THERAPIES
Available data to guide providers in counseling patients have been obtained from studies of implantable cardioverter-defibrillator (ICD) interrogations and interviews with families.
●Interviewing family members of deceased patients in a single practice found that approximately 20 percent of patients with ICDs had the device discharge in the last month of life .
●A retrospective chart review of 98 patients with ICDs from the Multicenter Automated Defibrillator Implantation Trial II who later died found that 15 percent chose to have their ICDs deactivated. Ten patients whose ICDs remained activated received shocks during the 24 hours before death .
- Lampert R, Hayes DL, Annas GJ, et al. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 2010; 7:1008.
- Goldstein N, Bradley E, Zeidman J, et al. Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians. J Am Coll Cardiol 2009; 54:371.
- Sherazi S, McNitt S, Aktas MK, et al. End-of-life care in patients with implantable cardioverter defibrillators: a MADIT-II substudy. Pacing Clin Electrophysiol 2013; 36:1273.
- Kinch Westerdahl A, Sjöblom J, Mattiasson AC, et al. Implantable cardioverter-defibrillator therapy before death: high risk for painful shocks at end of life. Circulation 2014; 129:422.
- Kramer DB, Mitchell SL, Brock DW. Deactivation of pacemakers and implantable cardioverter-defibrillators. Prog Cardiovasc Dis 2012; 55:290.
- Lewis WR, Luebke DL, Johnson NJ, et al. Withdrawing implantable defibrillator shock therapy in terminally ill patients. Am J Med 2006; 119:892.
- Barsheshet A, Moss AJ, Huang DT, et al. Applicability of a risk score for prediction of the long-term (8-year) benefit of the implantable cardioverter-defibrillator. J Am Coll Cardiol 2012; 59:2075.
- Kapa S, Mueller PS, Hayes DL, Asirvatham SJ. Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: results of a survey of medical and legal professionals and patients. Mayo Clin Proc 2010; 85:981.
- Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN. Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners. Pacing Clin Electrophysiol 2015; 38:917.
- Tajouri TH, Ottenberg AL, Hayes DL, Mueller PS. The use of advance directives among patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol 2012; 35:567.
- Kirkpatrick JN, Gottlieb M, Sehgal P, et al. Deactivation of implantable cardioverter defibrillators in terminal illness and end of life care. Am J Cardiol 2012; 109:91.
- Strömberg A, Fluur C, Miller J, et al. ICD recipients' understanding of ethical issues, ICD function, and practical consequences of withdrawing the ICD in the end-of-life. Pacing Clin Electrophysiol 2014; 37:834.
- Herman D, Stros P, Curila K, et al. Deactivation of implantable cardioverter-defibrillators: results of patient surveys. Europace 2013; 15:963.
- Pedersen SS, Chaitsing R, Szili-Torok T, et al. Patients' perspective on deactivation of the implantable cardioverter-defibrillator near the end of life. Am J Cardiol 2013; 111:1443.
- Raphael CE, Koa-Wing M, Stain N, et al. Implantable cardioverter-defibrillator recipient attitudes towards device deactivation: how much do patients want to know? Pacing Clin Electrophysiol 2011; 34:1628.
- Pasalic D, Gazelka HM, Topazian RJ, et al. Palliative Care Consultation and Associated End-of-Life Care After Pacemaker or Implantable Cardioverter-Defibrillator Deactivation. Am J Hosp Palliat Care 2016; 33:966.
- Goldstein N, Carlson M, Livote E, Kutner JS. Brief communication: Management of implantable cardioverter-defibrillators in hospice: A nationwide survey. Ann Intern Med 2010; 152:296.
- Wilkoff BL, Auricchio A, Brugada J, et al. HRS/EHRA expert consensus on the monitoring of cardiovascular implantable electronic devices (CIEDs): description of techniques, indications, personnel, frequency and ethical considerations. Heart Rhythm 2008; 5:907.
- FREQUENCY OF LATE-LIFE ICD THERAPIES
- INDICATIONS FOR DISCONTINUING CIED THERAPY
- Patient preference
- Perceived reduction in risk
- Device complications necessitating CIED removal
- DISCONTINUATION OF ICD THERAPY
- DISCONTINUATION OF PPM THERAPY
- Withholding versus withdrawing therapy
- Discontinuing pacemaker therapy in the nonpacemaker-dependent patient
- Discontinuing pacemaker therapy in the pacemaker-dependent patient
- ADVANCE CARE PLANNING
- Patients and advance directives
- Clinicians and advance care planning
- When patient and clinician beliefs differ
- LOGISTICS OF CIED DEACTIVATION
- SUMMARY AND RECOMMENDATIONS