Patient with pacer/AED is DNR

Jul 22, 2005 09:00 PM

by oldnewnurse

I work oncology and have not encountered this before. We have an end stage non-small cell lung ca patient with a cardiac hx and an implanted pacer with an AED. Medtronic is the brand. Today we made him a DNR. I asked the doc what about the defibrillator in the pacer should the man arrest. He told me to call Medtronic. I did. The company rep said they cannot come into the hospital and reprogram the pacer to deactivate the AED. What can anyone tell me about this?

Thanks

**dianah** · Jul 22, 2005, 10:48 PM

I assume the pt has an ICD, an implanted defibrillator anda pacemaker. As such, it will sense and defibrillate V-tach and stimulate the heart to beat if the rate falls below set parameters.

I would think the Medtronic rep could re-program it, at least, to change its sensing and output parameters. I'll have to ask our rep about this on Monday. They may be able to, if a specific doctor's order is written. Is the doctor you're dealing with the patient's own Cardiologist --- no, I see it's an Oncologist? The Cardiologist may be the one to write such orders, knowing the pacer and ICD better, as well as the scope of the Medtronic rep.

Anyone else have any thoughts? I have limited experience with ICDs, other than helping with a few implants. I wonder what a google or yahoo or vivisimo search would turn up . . .

hollyster · Jul 22, 2005, 10:54 PM

Our cardiologist shut off the ICDs not the reps. It is considered a medical procedure so the MDs have to do it.

BadBird · Jul 22, 2005, 11:19 PM

In the event of a cardiac arrest V. Fib, etc... you can shut it off by placing a magnet over top. We keep one on our med refrigerator.

mwbeah · Jul 23, 2005, 08:44 AM

Magnet inhibition

Originally Posted by BadBird

In the event of a cardiac arrest V. Fib, etc... you can shut it off by placing a magnet over top. We keep one on our med refrigerator.

It doesn't actually shut off, it is put into the asynchronous mode:

http://www.emedicine.com/emerg/topic805.htm

"Placing a magnet over a permanent pacemaker causes sensing to be inhibited by closing an internal reed switch. This temporarily "reprograms" the pacer into the asynchronous mode, where pacing is initiated at a set rate. Each pacemaker type has a unique asynchronous rate for beginning-of-life (BOL), elective replacement indicator (ERI), and end-of-life (EOL). Therefore, application of a magnet can determine if the pacer's battery needs to be replaced. Patients should carry a card that contains information about their particular pacemaker, since these rates are dependent on the manufacturer and the model."

Mike

Dinith88 · Jul 24, 2005, 08:35 PM

Yes, the rep can 'turn off the device' with a simple non-invasive procedure using one of their fancy portable defib/pacer interrogator-things. (about the size of a suitcase...and about as expensive as a Ferrari)

Absolutely needs an order from a doctor however.

I've seen it done by rep. and by doc...i dont think it matters who does it if there's a proper order written. (and perhaps THE DOCTOR needs to call the company)

IF you DONT remedy this situation, you may be setting this poor end-stage cancer sufferer up for a seriously uncomfortable experience as he's trying to die. I would get on this right away...it'd be a shame if he gets whapped...and zapped...and zapped again...and zapped...etc.

marieparn · Jul 26, 2005, 06:13 PM

Originally Posted by BadBird

In the event of a cardiac arrest V. Fib, etc... you can shut it off by placing a magnet over top. We keep one on our med refrigerator.

This recently happended to one of my patient's also. He was end stage CHF and the ICD kept firing appropriately but family and patient decided they wanted ICD shut off. Our cardiologist just use a magnet and place over the device. This will inhibit the ICD from firing.

Dinith88 · Jul 26, 2005, 06:52 PM

Originally Posted by marieparn

. Our cardiologist just use a magnet and place over the device. This will inhibit the ICD from firing.

This is true.

HOwever, in the OP's situation, the device still needs 'deactivated'.Sure, you can keep the magnet handy, HOWEVER you dont want to wait until this poor fellow is shocked (potentially several times) before you can run and slap it on his chest. And you cant just 'tape' or 'glue' a big weighty magnet to a patient's chest. NOt only would it be impracticle and silly, the patient may be pacer dependant (magnet will stop both pacer and icd)...in which case you may inadvertantly euthanize the patient.

Sure, the magnet is OK to have at the ready, however if the patient is a dnr and wants to go peacfully, the device needs disabled. Period.

**dianah** · Jul 26, 2005, 08:19 PM

Our dysrhythmia NP said she would make sure the physician has discussed all the pros and cons, and document the discussion and the pt/family's decision in the chart, along with orders to disable the unit. THEN the vendor may be called to do so (and they have done so at our facility, after the necessary discussion/documentation).

*jmgrn65* · Jul 28, 2005, 04:52 PM

Originally Posted by oldnewnurse

I work oncology and have not encountered this before. We have an end stage non-small cell lung ca patient with a cardiac hx and an implanted pacer with an AED. Medtronic is the brand. Today we made him a DNR. I asked the doc what about the defibrillator in the pacer should the man arrest. He told me to call Medtronic. I did. The company rep said they cannot come into the hospital and reprogram the pacer to deactivate the AED. What can anyone tell me about this?

Thanks

They can and do come in turn off the icd/pacemaker especially if hospice has been called. Maybe they weren't clear on the dnr status as in OHIO there are 2 dnr cca means we still treat and do until the patient arrests, dnr cc which means only comfort measures are done.

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Patient with pacer/AED is DNR

Patient with pacer/AED is DNR

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