ICD's and DNR's

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Specializes in Acute Care Cardiac, Education, Prof Practice.

I have a patient in with CHF exacerbation 100% V-Paced with an ICD as well, heading to rehab in the morning. The docs have sort of randomly shut the ICD portion of her pacemaker off, then turned it back on, then turned it off again. Each time we have questioned them they say, "well she is a DNR"

I understand not wanting heroic measures, but has anyone else had experience with and ICD and the DNR?

Tait

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No experience, but I understood DNR meaning long term, but a lot of docs still do short term medical management, if reversible that is, giving blood, etc. I am assuming it has to do with the family of the patient?

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Specializes in Cardiac, ER.

In theory the ICD could prevent an event that would lead to a code situation,..it could be that all he would need is a good shock and he's fine. I have seen the ICD's turned off if the pt is getting frequent shocks and doesn't want CPR, the psychological effect of frequent shocks is usually more than most people can handle.

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Specializes in Advanced Practice, surgery.

Tait, I have had one of these recently, and it was actually very difficult because the ICD kept firing and the poor patient who was so ready to go just wanted it all to end.

In the end we turned the ICD off (it fired 17 times within one morning) and the discomfort and distress was unbearable for her. She died later that afternoon, but I do think that if there is a DNAR then after that experience the ICD should be switched off

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Specializes in Acute Care Cardiac, Education, Prof Practice.
Tait, I have had one of these recently, and it was actually very difficult because the ICD kept firing and the poor patient who was so ready to go just wanted it all to end.

In the end we turned the ICD off (it fired 17 times within one morning) and the discomfort and distress was unbearable for her. She died later that afternoon, but I do think that if there is a DNAR then after that experience the ICD should be switched off

I can understand that case for sure. However this patient is independent, active, alert and doing well. I would think they would leave it on until she at least began to exhibit strong signs of decline.

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Specializes in Cardiac Telemetry, ED.
I can understand that case for sure. However this patient is independent, active, alert and doing well. I would think they would leave it on until she at least began to exhibit strong signs of decline.

I would think so too. How old is she?

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Specializes in Acute Care Cardiac, Education, Prof Practice.

She is a strong 85 year old. Tiny and walks a little slow, but overall a good specimen ;)

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Specializes in Spinal Cord injuries, Emergency+EMS.

i think the other replies show the sensible route

valid DNAR and frequent shocks - the team and the patient if competent need to make a decision in the patient's best interests ...

a competenent patient could request the iCd be turned off any way...

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Specializes in ICU, ER (ED), CCU, PCU, CVICU, CCL.

We recently did something simular. I work in the cath lab where we implant ICD's. A pacer rep came into to change an algoryhtm on a DNR pt to "one shock only". There are many was to program an ICD not to fire or just to over drive pace VT first before it delivers a shock. Often they just disable the defib side but the devie will still train drive (pace) out the VT.

It comes down to a pt's choice and a well informed family and making THEIR WISH KNOWN TO US.

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Specializes in Cardiac Telemetry, ED.

I suspected she might be of advanced age. Sounds like the patient was involved in the decision, and maybe she just figured she'd lived 85 years, and what happens happens. A healthy attitude, I think. The fact is, that at 85, if she did have an event that resulted in some self care deficits, what would her quality of life be at that point? At her age, she could begin to decline very rapidly, and then what kind of quality of life would she have? Would her family members make the right decisions for her? There really is a lot to consider, and mere survival might not be sufficient for many. Making these decisions while one is still able to do so is important to a lot of people.

Right now I'm taking care of an 87 yo LOL who is a full code, despite having many comorbidities and in obvious decline, both physically and in mental status. The family members do not see the writing on the wall, so if she does code, I will be performing chest compressions on a frail LOL who must weigh about 90lb. It's not a thought that I want to contemplate.

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Specializes in Acute Care Cardiac, Education, Prof Practice.

So I talked more with the day nurse about this today. Apparently there is some concern that she may decline in the near future, very quickly. They have hesitated a few times, like I noted, turning it off, then the next day turning it back on. However I do believe now that she was involved in the process because she had verbalized that when the ICD shocks her she does feel pain.

Thanks for all the comments :)

Tait

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