implantable defibrillators/pacers

marachne · Jul 23, 2008

I have seen someone who has been shocked by their defibrilator -- they weren't actively dying, but w/i about 3 days of death. There had been several discussions w/the patient about deactivating and he wasn't ready...until he was shocked. At that point he wanted it deactivated, but it was the weekend. We had a large magnet that we taped to his chest over the defibrilator, no more shocks. Every hospice should have those magnets on hand for such an instance.

leslie :-D · Jul 23, 2008

we have a couple of magnets as well.

problem is, these options haven't always been discussed w/the pt...

until i saw one of my pts getting zapped and zapped and zapped.

i told doc that if he didn't discuss it, i would...

which was fine w/him. :rolleyes:

still, many choose to keep them activated.

leslie

aimeee, BSN, RN · Jul 24, 2008

You really can't make generalizations about defibrillators because there are different models and they can be set up with different parameters for firing. We have had a time or two where the patient has been repeatedly shocked during the dying process and it is very difficult for the family to witness this. It can definitely interfere with a peaceful exit but that is not the norm. Still, who wants to take that kind of chance? Even the magnet solution is not 100% because the defibrillators CAN be set so that a magnet will NOT deactivate it. You have to call the rep and check on the settings of that particular device. One thing that can be done, short of deactivating, is to ask for the parameters for firing to be set so that the conditions are much less likely to cause firing. Sometimes patients and their families are much more comfortable with changing the parameters than with "turning it off". They have been told they need this device to live so its often very hard for them to think about turning it off completely. So here's my tips:

1. Get the info from the card with the specific device and the emergency contact for the device rep.

2. Call them and find out if a magnet will deactivate the device

3. Find out what their protocol is if it needs to be turned off in the middle of the night or on a weekend. (Some demand to see an order from the physician before they will go out)

4. You may be able to get medical magnets from your local cardiologists office that are specially made just for this purpose. (We were gifted with 2!) If you can't, see if the device rep will tell you what strength magnet you need.

5. Figure out a good place to keep the magnets that everybody agrees on so you will have them at the ready so when it happens at 3 am on a Saturday night you know right where to go for them.

marachne · Jul 24, 2008

One other comment about the magnets (at least in my experience) these puppies are big and heavy (the ones where I used to work were doughnut shaped, about 6 inches in diameter and probably weighed a few lbs). The one pt we had one on during my tenure was very chachetic. His defibrillator/pacemaker was protruding from his chest, pulling at his skin, and then we put this heavy magnet on it -- I was really concerned about skin breakdown and discomfort. If you can get it reset (I like that idea of changing the settings as a compromise) or turned off, it really is preferable, but as aimee stated, something that has kept one alive for so long is a hard thing to give up.

miriam

dailysong · Jul 25, 2008

I ran into this and remember huge difference between defibrillator and pacemaker. Pacemaker isn't a problem but the defibrillator can and has fired and it's awful! Don't forget, this is a huge legal area. Our facility has no written policy on this; I suggested they write one since we'll only see this more and more. We're not allowed to do anything to deactivate; not even put the magnet near the patient. We can only educate and refer patient/family to MD that monitors it for patient.

leslie :-D · Jul 25, 2008

One other comment about the magnets (at least in my experience) these puppies are big and heavy (the ones where I used to work were doughnut shaped, about 6 inches in diameter and probably weighed a few lbs). The one pt we had one on during my tenure was very chachetic. His defibrillator/pacemaker was protruding from his chest, pulling at his skin, and then we put this heavy magnet on it -- I was really concerned about skin breakdown and discomfort. If you can get it reset (I like that idea of changing the settings as a compromise) or turned off, it really is preferable, but as aimee stated, something that has kept one alive for so long is a hard thing to give up.
miriam

ours are circular and heavy as well...

and are a nuisance to keep on the pt...esp if pt is restless and meds aren't working.

once we know the basic rhythm pt is presenting with, most times doc will not authorize settings to be altered with.

he strongly feels that families/pts aren't ready for these type decisions.

knowing that they're actively dying, he ups the meds considerably, to override the shocks delivered.

it really is much different than dealing w/pacemakers.

and i have found that most families/pts feel that you're altering one of their internal organs when you bring up resetting icd.

tough situations, for sure.

leslie

marachne · Jul 25, 2008

ours are circular and heavy as well...
and are a nuisance to keep on the pt...esp if pt is restless and meds aren't working.
once we know the basic rhythm pt is presenting with, most times doc will not authorize settings to be altered with.
he strongly feels that families/pts aren't ready for these type decisions.
knowing that they're actively dying, he ups the meds considerably, to override the shocks delivered.
it really is much different than dealing w/pacemakers.
and i have found that most families/pts feel that you're altering one of their internal organs when you bring up resetting icd.
tough situations, for sure.
leslie

In your comment about families/pts having strong feelings about the icd, I can see the seeds for your doc's attitude, but for a unilateral statement from him/her that "families/pts are ready for these types of decisions" seems a bit strong -- shouldn't it be a matter of discussing the options and letting them choose? Also, I think that attitudes can change, particularly if somene is getting a bunch of shocks....

just musing...

It is an topic that is going to get more and more attention as more people with ICDs reach the end of their life. Apparently there are some guildelines being developed. Check out the rest of the posts on Pallimed if you're curious

leslie :-D · Jul 25, 2008

In your comment about families/pts having strong feelings about the icd, I can see the seeds for your doc's attitude, but for a unilateral statement from him/her that "families/pts are ready for these types of decisions" seems a bit strong -- shouldn't it be a matter of discussing the options and letting them choose? Also, I think that attitudes can change, particularly if somene is getting a bunch of shocks....

no, this md is great.

and he has had these discussions at beginning of hospice.

i think it's a balancing act, betw pt/family being in acute throws of disease and its adversities and trying to prevent further stressors.

he feels meds can ablate most of symptomology.

this guy has opened palliative care units in hospitals, and has a tremendous amt of experience.

not that i agree with him on everything, but will admit he knows his stuff for the most part.

i'm only thinking of a couple of pts that were repeatedly getting zapped.

both pts/families were in extreme denial and were fighting til the end.

i suppose that's why he wouldn't approach the subject again.

when he gave me permission to bring it up to one of the pts, the dtr screamed at me: "what are you trying to do, kill my mother???"

but yes, i do agree w/you about giving pts the choice.

leslie

RNWithAHeart · Jul 27, 2008

I have just entered into Hospice, came from a telemetry background. I have seen many occasions in tele where a pt is being discharged to Hospice and the ICD is turned off before they are discharged from the hospital.

Sabby_NC · Jul 27, 2008

Excellent posts as I have had this issue many times very recently and have a Surgeon with a device at this time.

I am proactive in forward planning for my patient's death so I always discuss this with them all and the device is turned off at the time the pt starts to actively die.

I have as yet not had one that did not want the device deactivated.

Amazing how things in your own clinical setting happen at the same time to others.

I appreciate all of the posts and advice. :yeah:

Ruthfarmer · Jan 18, 2011

A colleague and I were discussing this topic in regard to one of the patients on our hospice service. The cardiac specialist involved was adamant that he would NOT order the defibrillator shut off as that would be euthanasia. My thought is: what about the patients' right to consent to or refuse a treatment? Once a patient gets an implanted device, they are no longer allowed to refuse the use of it? I'm going to suggest to my colleague that she approach the MD in question and ask about changing the settings on the device. I suppose the patient could ask to be under another MD's care? Any other insights anyone has to offer would be much appreciated.