Tuesday, May 31, 2016

Missed opportunities to avoid painful shocks at the end of life


Public Release: 23-Mar-2016
Missed opportunities to avoid painful shocks at the end of life
Many patients unaware of benefits of deactivating implantable cardioverter defibrillator
American College of Cardiology

Many patients who have a common medical device known as an implantable cardioverter defibrillator (ICD) are unaware that the device can be deactivated to prevent painful shocks in their final days of life, according to two studies scheduled for presentation at the American College of Cardiology's 65th Annual Scientific Session.

The Heart Rhythm Society and the European Society of Cardiology have issued recommendations encouraging physicians to inform patients about the benefits of deactivating an ICD when death is near, yet recent studies show that up to 31 percent of people with an ICD receive shocks in their last day of life. Two new studies add further evidence that doctors are not consistently implementing these recommendations, which the authors said may reflect a reticence to engage in difficult discussions about end-of-life decisions.

"When you reach the stage of palliative care, sometimes the ICD doesn't have a role in caregiving anymore," said Dilek Yilmaz, M.D., a Ph.D. fellow in cardiology at the Heart and Lung Center of Leiden University Medical Center in the Netherlands and lead author of one of the studies. "If a person is dying of a terminal cancer, for example, the ICD is not going to prolong their life, but it is fairly likely to cause pain in their last hours and prevent them from having a peaceful death."


ICDs are battery-powered, surgically implanted devices used to prevent sudden death in people with certain conditions, such as sustained ventricular tachycardia or fibrillation, that put them at risk for life-threatening heart rhythms. If the device detects a dangerous heart rhythm, it issues a shock to restore a normal heartbeat. ICDs are extremely common, with 10,000 implanted each month in the United States alone, according to the American Heart Association.

The device can be deactivated using a computer in any cardiologist's office, with no need for additional surgical intervention. Because ICDs do not maintain the heart rhythm on an ongoing basis like a pacemaker does, deactivating the device does not actively hasten death. However, if a patient experiences a dangerous heart rhythm--a common occurrence during the natural course of death from any cause--a deactivated ICD will not intervene to rescue the patient.

"These shocks are often much more frequent on the patient's last day than any other day of their life," said Silvia del Castillo, M.D., a cardiologist at Hospital Universitario de Fuenlabrada in Madrid and lead author of the second study. "I think it's cruel in many cases to leave the ICD on until the very end, and when doctors don't provide enough information about deactivation or delay that conversation until the final hours, it undercuts the patient's right to make their own decisions."


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