Patient with pacer/AED is DNR

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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

Specializes in Cardiac, Post Anesthesia, ICU, ER.

I am not sure which ICD don't turn off with the use of a Magnet, but in the few cases I've seen in which a patient decided to become a DNR, and make that choice to die if that is their will, our Pacer Magnets deactivated the AICD without any problems, and the patients were left to die a natural uninterrupted death.

Are there any certain brands that anyone knows of that definitely WILL NOT deactivate with the use of a magnet???

Another issue that I don't understands some's position on is the nurse placing the Magnet on a DNR patient??? A Physician is not needed to ensure that we give our patients the top quality comfort care if they've made the decision to allow there life to have a natural ending by deactivating the ICD, each of us should be familiar with the procedure to ensure we can give our patients the best care in life and in impending death.

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With the recent problems with some Guidant devices, many of the magnetic reed switches were turned off, meaning that they will not respond to a magnet in any way. In Guidant devices, this feature is programmable. In Medtronic devices (and most devices are Medtronic devices), a magnet will disable detection. As an interesting twist, devices made by CPI (a predecessor to Guidant) will have their detection disabled permanently by magnet application UNTIL a person with a programmer turns it back on again. This isn't an issue in folks who are DNR, but it is an issue with the OR.

It really is easier to get an order to have a rep turn the detection off if the patient desires it. It usually isn't a big deal. Remember that turning detection off is quite different from turning pacing off. The two are not related in an ICD.

Does this make sense? I hope this clears it up.

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Specializes in Cardiac, Post Anesthesia, ICU, ER.
It really is easier to get an order to have a rep turn the detection off if the patient desires it. It usually isn't a big deal. Remember that turning detection off is quite different from turning pacing off. The two are not related in an ICD.

Does this make sense? I hope this clears it up.

In the ones I've seen, the MAGNET shut the whole system down. But this statement kind of irks me, "It really is easier to get an order to have a rep turn the detection off if the patient desires it." If this is how some people are functioning, they are very poor pt. advocates, unless you have a rep right there on your unit to shut it off as quickly as you yourself could. The handful of occasions I've been involved with were situations in which the patient was suffering and was ready to accept the inevitable and kept being pulled back by the pacer, on a couple occasions, the Dr. placed the magnet on and on a few, the nurse did the "Medical" procedure. :uhoh3:

Still today as nurses continue to become more and more empowered too many are too passive to step forward, which is why many nurses still make about the same amount as an uneducated construction laborer.

Turning pacing off is extremely controversial and would have to be done by the physician (or the HOSPITAL'S device RN/tech--as no device company will do that). I've been at places where turning off a pacer had to go through a review by the ethics board and legal affairs first. It's a pandora's box, trust me.

Obviously, you haven't been involved with many end of life situations when the patient comes to the hospital in severe CHF and Renal Failure and is ready to die and keeps being held on by a defibrillator that shocks him back into a viable rhythm, which only prolongs his misery. And these cases will almost inevitably happen on a late Friday night, or sunday morning when there is no "Rep" around, and the Doctor is not available. In all 5 that I can remember type situations like this, none of them was at 10 a.m. on a weekday morning when the Guidant or Medtronic Rep just happened to be there!!!!

Sorry for the rant, but several here sound like they are not the best of patient advocates, if they want to call a rep to come shut off a repeatedly firing device because they don't want to be the person taking "responsibility" for the patient's inevitable death. As nurses we have a responsibility to take care of our patients and meet their needs in both life cycles and death cycles. And YES, this does mean pushing that 10 mg of MSO4 on the patient who in a DNR, but is having that awful agonal resp. and is exhibiting the wonderfully saddening "Air Hunger" while the family sits by and helplessly watches. And at that time you're taking care of the family moreso than the patient, but that is still included in the job description. If you don't like it, don't take the job.

Doug

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Whoa, boss:

I'm not saying that you can't put a magnet on it. I just think it's kinda irresponsible to assume that the magnet will magically take care of the problem. An ICD (or even a pacemaker) is a complicated device--it's a computer. It's just not always as simple as putting a donut magnet on it. These devices become more complicated each month and they need someone who is trained to interact with them. It's a specialty in it's own right.

If you need to turn the thing off, you should be sure and have someone who knows what they're doing--be it a tech, an RN, or a rep who has been trained (and has the equipment) actually turn detection off. Most hospice nurses that I know are totally aware of this.

Also,

1. You absolutely need an order to turn detection off, period. There's a difference between being a good patient advocate and going way outside one's scope. I doubt the Board of Nursing will accept that argument for overstepping your boundaries, it's just not worth your license. That being said, a properly trained person (including an RN) can do it with a programmer with a proper order. I mentioned turning pacing off earlier. It's radically different.

2. Every company and many large hospitals have people on call for pacers and defibrillators 24/7. I've never had a problem finding somebody to take care of something, if I needed it. If someone won't come in the middle of the night, then you need to address their crummy service. Yes, if you're in the middle of Alaska, that can be a problem. But for most, especially those closer to large cities, it's not.

3. A magnet will not "shut the whole system down." All defibrillators made within the last several years have pacemakers built in. As I've pointed out, placing a magnet on such a device may "blind" the device to VT or VF but it will not stop pacing. It can't. If you place a magnet on a pacemaker (a plain ol' pacemaker), it will force the pacemaker to pace at the magnet rate (which varies by manufacturer). It ABSOLUTELY will not turn a pacemaker off.

The reason I said these things is because I've been involved in this situation plenty of times. If the time has come to turn the detection off, then the patient deserves to have it done correctly. That's my point. I did not intend to argue end-of-life issues, or anything like that. I agree that nurses are often too passive when it comes to end-of-life issues (and many issues in general), but for crying out loud, let's make sure stuff is done right--especially in situations like this.

Thanks:saint:

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I watched a family member go through this we had hospice at home.I had legal advance directives on file in cardiologist office,Wednesday pt lapsed into coma,pupils fixed and nonreacitive,bp 60 by palpation.pulses not felt except femoral and carotids,pacemaker and HR 60 bpm.rr 6 to 10 per minute.no urine or wetness noted.Thursday-rectal temp 97.0,O2 sat not readable on earlobe,no bowel sounds.Friday,Sat.and Sun continues downward.rr rate by Sunday 2 to 3 per minute,no carotid or femoral pulses.HR 60bpm,legs and arms rigid and cool,dusky color.Called cardiologist on Monday,Tuesday and Wednesday.He refused both monday and tuesday.his nurse cite "it would be euthansia"I have been an nurse for 37 years,did hospice 20 years.On Wednesday rep came but refused to turn it off.she lower it to 30 bpm.death finally came 12 hours later.Funeral called 6 hours later stated if we wanted open casket we needed to bury the next day.later they were comfortable enough to tell me they had difficulty with embalment due to circulation being down so long.I still have nightmares 8 weeks later.

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

Okay....from a hospice perspective. When the person signs a DNR we contact the cardiology office immediately and request a visit to the pt home, next day, to deactivate the ICD. We don't care who comes, we simply want it off, and the offices comply with very few problems....this, by the by, is for the greater Ann Arbor, Detroit area. The offices ALWAYS send their own staff...not some company rep... Sometimes the patient is well enough to travel to the office themselves next day...that is okay too...it is just imperative to have the ICD off in a DNR.

Pushing 10mg of Morphine is not likely to do anything harmful for the "air hungry" patient...it will likely make them more comfortable. If the patient dies shortly after the med DO NOT think that you killed them with the morphine...you did not....you simply provided some comfort at the end of their life.

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

Our hospice pt's have their devices deactivated as well by the cardiologist once the pt is placed on hospice, usually done in the office visit. BTW, my father in law (14 yrs ago) was put on hospice and AICD wasn't deactiivated, my husband and his siblings as well as the nurses said it was a horrible death he was shocked over and over. Everytime they thought he had passed, it went off again, just horrible,

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Specializes in critical care transport.

Wow. This is a good thread. I had admited a pt with a COPD/ CHF exacerbation. Rapid Response team was called within 8 hours of her placement to our floor. She was a DNR. I had seen they had put her in a special care unit when I had come back from work. I can see from my station the rhythms on her unit as well as my own, and I had looked up to see her name and below it, pacer marks with either nothing after it or agonal looking waves. Finally, nothing but pacer spikes. This question was raised in my own mind. I did not know if she was made comfort care in addition to her DNR DNI status. Very good thread for my own recent experience.

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As far as I know the doctors diactivate it with a magnet ..........

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