Implantable Cardioverter Defibrillators The Challenges'

1
Implantable Cardioverter Defibrillators The
Challenges.

• Pam Ransom.
• Macmillan CNS.

2

• Why Me?

3
Liverpool Care Pathway.

• Multidisciplinary plan/template of care for all
  at end stage of life.
• Promotes patient-centred, collaborative care
  utilising evidence-based guidelines.
• Version 11 of the LCP incorporated deactivating
  of ICDs within goal 3.
• As with all goals of care supplementary
  prompts/information education is the norm.

4
Local discussions highlighted.

• Lack of knowledge regarding ICDs within the
  generalist field.
• Lack of knowledge within the specialist
  palliative care field also.
• Limited information available for patients
  regarding deactivation.
• There appears to be disparity when discussing
  deactivation within clinical practice.

5
Background to ICDs.

• An ICD is used to treat two types of rhythm
  disturbance, ventricular tachycardia
  ventricular fibrillation, by constantly
  monitoring heart rhythm. If it senses either of
  these abnormal rhythms, it delivers an electrical
  impulse or shock to return the heart back to
  normal.
• An ICD can effectively prevent sudden cardiac
  death.

6
(No Transcript)
7
Implantable Cardioverter Defibrillator.

• A mini-computer consisting of
• lt a pulse generator with batteries a capacitor
  that can send a powerful shock to the heart.
• lt an electronic logic circuit to tell the ICD
  when to discharge.
• lt lead electrodes placed in the heart (or rarely
  , small electrodes placed under the skin) to
  sense the cardiac rhythm deliver shock to the
  heart muscle.

8
Issues at End of Life

• ICDs can prevent premature death from
  arrhythmia but may also prolong the dying process
  and make it more distressing.( Lynn,2005)
• The shocks delivered can be painful thus are
  inconsistent with comfort care.(Harrington,2004).
• Patients with ICDs often suffer progressive
  co-morbid cardiac conditions, many of who may
  decline CPR.
• Dying patients are at risk of receiving
  inappropriate shocks in the terminal phase of
  illness.

9
Indications for Deactivation.

• Continued use of an ICD is inconsistent with
  patient goals.
• Withdrawal of anti-arrhythmic medications.
• Imminent death- activation inappropriate in the
  dying phase.
• While an active DNR order is in force.

10
Disabling an ICD

• Treatment decisions involving ICD deactivation
  are unavoidable.
• Discussions may be initiated by patients their
  carers or the Physician- stimulated by 1 of 3
  possible concerns
• 1) some patients will no longer value continued
  survival.
• 2) the ICD no longer offers the prospect of
  increased survival.
• 3) the ICD impedes active dying.

11
Time to discuss Deactivation

• Should planning for the eventual death be a
  standard part of the consent process the
  ongoing management for anyone accepting such a
  device?
• The need to discontinue use of the ICD is not an
  occasional consideration it is a predictable part
  of the course of dying for any patient with an
  ICD who will die a natural death.

12
Discussing Deactivation

• Consult the ICD Physician.
• When discussing the expectations of turning off
  the ICD the following should be made clear
• lt the device will no longer provide life-saving
  therapy in the event of a ventricular
  tachyarrhythmia.
• lt will not cause death.
• lt will not be painful, nor will its failure to
  function cause pain.
• Establish a plan of care ensuring availability to
  address new questions.
• If there are conflicts, consultation with the
  palliative care team may be helpful.

13
Implications for practice.

• We need a mechanism / standard in place now for
  when we become swamped! (if the number of
  patients were to increase by 10 then our current
  system would not work)
• Is there a need to kwell the myths?
• Improved links between all health professionals
  involved.

14
Work in Progress

• North Tyneside currently collaborating with the
  Network to develop this standard.
• Communication training continues to be delivered
  across all health-professional groups.
• Joint education/networking continues to expand.
• Recognising the dying phase and acknowledging
  barriers preventing this are key to providing a
  Good Death'. How well do we diagnose the dying
  phase in this group of patients?

15
Key take home message..

• Good palliative care is an exercise in
  anticipation.
• Failure to plan ahead puts the patient/family in
  a position of substantial unwarranted risk of
  well-being.
• Those of us who work downstream could be left
  enduring the harms with patients/families those
  upstream never realize the problems that they
  cause.

16
Thankyou