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ICDs and Hospice
Abstract & Commentary
By John P. DiMarco, MD, PhD, Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville. Dr. DiMarco is a consultant for Novartis and does research for Medtronic and Guidant.
Source: Goldstein N, et al. Brief communication: Management of implantable cardioverter defibrillators in hospice: A nationwide survey. Ann Intern Med. 2010;152:296-299.
In this report, Goldstein et al detail the results of a nationwide survey conducted among hospice administrators on their policies regarding patients with implantable cardioverter defibrillators (ICDs). The authors sent a survey questionnaire to almost 800 hospices. Responses were obtained from 414. The survey asked an administrator whether or not their facility had admitted patients with active ICDs, whether any of these patients had been shocked in the past year, and whether any patient had received multiple shocks. They also asked if the hospice intake form had a question to identify patients with ICDs at the time of admission, whether the hospice had a formal policy for deactivation of an ICD, and whether the hospice had a magnet on hand that could be used for emergency deactivation.
The response rate to the survey was 50%, with 414 hospices completing the questionnaire. The mean daily patient census was 116, with patients having a mean length of stay of 62 days. A mean of 15% of patients had heart disease as the diagnosis qualifying them for hospice admission. Although most centers had cared for ICD patients, admission of a patient with an active ICD to hospice was relatively infrequent. Only 1-10 such patients were admitted by 76% of the respondents, and 11-25 by 6% of the respondents. Only 3% admitted more than 25 patients over the past year. Only 20% of the hospices had a question on their intake form specifically identifying ICD patients, and just 10% had a written policy for deactivating ICDs. This was noted despite the fact that 58% of the hospices reported that one or more patients had been shocked by an ICD during a hospice stay and 40% reported that at least one patient had received multiple shocks. Only 25% of the facilities had a magnet on hand to deactivate the device. If a deactivation was planned, a variety of approaches were employed. These included the patient being transported to a clinic (34%), a member of the hospice team turning off the device (14%), a non-hospice health care provider coming to deactivate the device (31%), or a device manufacturer representative deactivating the device (47%).
The authors conclude that improvements in management of care for patients with ICDs in advanced disease are needed. They encourage hospices to provide a simple policy to improve outcomes for patients with ICDs and their families.
There is still confusion in the medical community about the best policy for managing patients with implantable defibrillators and pacemakers at end of life. It is legally and morally clear that patients have a right to refuse therapy from external devices, but many physicians remain uncomfortable discussing the device deactivation with their patients, and patients may not regard an ICD as extraordinary therapy. Defibrillators are somewhat different than pacemakers since their defibrillation function is used only intermittently to terminate potentially life-threatening arrhythmias. Pacemakers are often necessary continuously to support normal activities.
Once patients are admitted to hospice, they have usually acknowledged they do not want extraordinary life-prolonging interventions, and the appropriateness of ICD therapy is, therefore, questionable. In this paper, however, Goldstein et al demonstrate that hospice policies lag behind the clinical use of ICDs. Only a small percentage of hospices made efforts to identify patients with ICDs, and only a small fraction had specific policies concerning deactivation. Since the major reason for hospice admission was often not a cardiac diagnosis, it is likely that a cardiologist was not involved in the admission to the hospice at all. As a result, a larger number of hospices reported that patients had received what were probably inappropriate shocks, and some had even received multiple shocks.
The Heart Rhythm Society is preparing a set of guidelines for managing patient with ICDs and pacemakers at the end of life that should be released later this year. These guidelines have been greatly needed. If hospices combined use of the sample protocol given in this paper with the recommendations in the upcoming guidelines, patients should benefit.