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How to initiate a difficult conversation
Explain benefits and burdens of ICDs
The ideal time for a patient to learn about the potential need to deactivate the electrical shock feature of an implantable cardioverter-defibrillator (ICD) is when the decision to implant the device is made, says Chuck Wellman, MD, FAAHPM, chief medical officer at Hospice of the Western Reserve in Cleveland, OH.
"Unfortunately, the internist, family practice specialist, or cardiologist is not going to bring up this topic," Wellman says. "I understand that at that point in time, the physician and patient are fighting to prolong life. It becomes the hospice staff's responsibility to discuss deactivation because we are the ones providing care at the end of life."
Before hospice staff members can initiate the conversation related to ICD deactivation, they have to identify patients with ICDs, says Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine (AAHPM) in Glenview, IL. Once the admissions nurse knows that the patient has an ICD, information about the manufacturer and type of device must be obtained, Storey says. "Patients and family members usually have this information, and manufacturer's representatives are willing to talk to nurses about the devices," he says.
The next step for nurses at Four Seasons Hospice and Palliative Care in Flat Rock, NC, is to find out what the device does, says Janet Bull, MD, chief medical officer of the agency. Bull points out that ICDs perform different functions, depending on the patient's needs:
pacing with mild ventricular tachycardia, few pacing signals;
cardioversion if pacing stops, mild shock given (thump);
defibrillation with ventricular fibrillation, large shock (strong kick);
pacer with bradycardia, pacing set for specific beats per minute.
The nurse makes sure that patients and family members understand the action of the device and finds out if the patient wants to be kept alive by ICD if quality of life is poor and the patient is declining, says Bull. Because deactivation is a simple process, using a programming wand linked to a computer, it does not cause any pain or require an invasive procedure, she says.
"We explain that we can disable the shocking component without disabling the pacer component," Bull says. "It is also important to point out that deactivation is consistent with a do-not-resuscitate order."
If a patient agrees to deactivation, plans are made to have the manufacturer's representative come to the home to disable the device, or if the patient is ambulatory, take the patient to a doctor's office or a clinic, says Wellman.
Although a patient initially might decide to leave the ICD's shocking program activated, as the patient declines and metabolic changes trigger the shocks, the patient and family might want it deactivated, Wellman points out. If there is no time to have someone come to the home to deactivate it, the hospice should have a plan to use a magnet to deactivate it, he says.
Nathan Goldstein, MD, assistant professor at the New York City-based Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, NY, says, "This is a difficult conversation for any health care provider to have with patients and families, but hospices are good at difficult conversations. It's important to have policies that make sure these conversations take place."