Palliative Care Consultation and Associated End-of-Life Care After Pacemaker or Implantable Cardioverter-Defibrillator Deactivation

Abstract

The presence of cardiac pacemakers and defibrillators complicates making end-of-life (EOL) medical decisions. Palliative care/medicine consultation (PCMC) may benefit patients and primary providers, but data are lacking. We retrospectively reviewed 150 charts of patients who underwent device deactivation at our tertiary care center (between November 1, 2008, and September 1, 2012), assessing for PCMC and outcomes. Overall, 42% of patients received a PCMC, and 68% of those PCMCs specifically addressed device deactivation. Median survival following deactivation was 2 days, with 42% of deaths occurring within 1 day of deactivation. There was no difference in survival between the groups. The EOL care for patients with implanted cardiac devices is complex, but PCMC may assist with symptom management and clarification of goals of care for such patients.

Palliative care in patients with heart failure

“…85 86 Consultation with palliative care can help clarify the goals of care. 87 Deactivating an ICD does not result in almost immediate death as it does with an LVAD. Discussions around end of life and deactivation in people with LVADs are especially complicated.…”

Exploring Advance Directive Perspectives and Associations with Preferences for End-of-Life Life-Sustaining Treatments among Patients with Implantable Cardioverter-Defibrillators

“…Device deactivation is a critical element of ACP discussions in ICD recipients [11,14,16], but related evidence was sparse in both Western and Asian countries. This lack of discussions often leads to recipient devices being active near EoL, inducing urgent requests for deactivation [15,16].…”

“…However, a trade-off of the survival advantage of ICDs is often observed, which involves a broader spectrum of distressful post-implant adjustment associated with lifestyle changes as well as management of the underlying cardiac conditions and/or other comorbid conditions [11]. Furthermore, ICD recipients may face complex palliative medical decisions, including the deactivation of an ICD at the end-of-life (EoL) [12][13][14]. Particularly, the shock function of ICDs often occurs near death [15,16], which may lead to meaningless prolongation of life [12].…”

“…Particularly, the shock function of ICDs often occurs near death [15,16], which may lead to meaningless prolongation of life [12]. One approach to facilitate informed decision-making for future palliative care and avoid complicating EoL care is the early introduction of advance care planning (ACP) and/or advance directives (ADs) [12,14,17,18]. Through such a process, healthcare providers may better assist ICD patients and family members with ICD management [14,16] while also addressing the timely deactivation of ICDs as an essential component of ACP to improve patient care [11].…”

“…A possible reason for the lack of attention to ACP/AD discussions is that ICD is primarily considered a life-saving therapy. Thus, its deactivation could be regarded as a complex and controversial issue, leading to delayed discussions and complicated EoL medical decisions [14]. The reported barriers to AD discussion from professionals, patients, and/or institutions are a result of lack of professional training, the knowledge deficit of patients regarding device deactivation [17], or a lack of a relevant policy or system guiding device deactivation [16].…”