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Deactivation of ICD’s in End of
Life Care
Presented by Sister Sarah Collitt
Electrophysiologist Specialist Nurse
What is an Implantable Cardiac
Defibrillator?
• Defibrillates patients at risk
of VF/VT
• Gained FDA approval in
1985
• Primary or secondary
prevention
• Can also pace the heart
• Shocks are painful
How many ICD’s are there?
• Tertiary Cardiology Centre
• Implant 15-20 ICD’s a month
• 700-800 device procedures per year
• Not all hospitals manage ICD’s
Nurse, how do I die?
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Defibrillator function is deactivated peri-operatively or at end of life
Deactivation can be permanent or temporary using a ring magnet
Pacing function is often left switched on
Alarms are switched off at deactivation
ICD’s must be removed before post-mortem or cremation
Patient will not die immediately
Advanced Care Planning
• What are the patients wishes?
• Is there an Advanced Directive?
• Lasting Power of attorney?
• Timely deactivation of ICD
• Nurse at home? Hospital? Hospice?
Three triggers for Supportive/ Palliative Care - to identify these
patients we can use any of the following methods:
1. The surprise question, “Would you be surprised if this patient
were to die in the next 6-12 months” - an intuitive question
integrating co-morbidity, social and other factors.
2. Choice/ Need - The patient with advanced disease makes a
choice for comfort care only, not ‘curative’ treatment, or is in
special need of supportive / palliative care.
3. Clinical indicators - Specific indicators of advanced disease for
each of the three main end of life patient groups- cancer, organ
failure, elderly frail/ dementia
Is the ICD patient at end of life?
Most ICD patients have heart failure
40% will die within a year of diagnosis
Ageing population means more people are living with heart failure
Patients have multiple comorbidities
Carries a heavy burden of symptoms
Disease trajectory is exceptional in it’s unpredictable trajectory
Key end of life indicators in heart failure
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refractory symptoms
three hospital admissions in less than six months
experience multiple shocks from their device
comorbidity
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End of life care in heart failure A framework for
implementation;NHS Improvement 2010
Communication
Effective communication between patients and clinicians is fundamental.
We know patients and their carers value it highly. We also know it is
sometimes poor.’ Professor Sir Mike Richards
We met as an MDT and discussed how to discus end of life with all ICD
patients of all ages.
Initially we found the discussion uncomfortable
Development of Cardiac Network policy to improve care at other
hospitals/hospices.
Communication training
Maguire Unit provides training for CONNECTED Advanced
Communication Skills Training based at Chrisites
• Do not attempt resuscitation (D.N.A.R)
• Advanced care planning
• Breaking bad news (SPIKES)
• Handling anger & distress
• Confronting colleagues
• 2 & 3 day courses
SAGE & THYME ®
3 hour course designed at SMUHT
Designed to train all grades of staff how to listen and respond to
patients/clients or carers who are distressed or concerned.
Jenny 49yrs
•VT ablation 1992
•AV nodal ablation and permanent pacemaker 1994
•Previous tricuspid valve endocarditis
•Biventricular ICD 2006
•Ejection fraction 20-30%
•Ehlers-Danlos syndrome
•BIPAP for diaphragmatic muscle disease
•Total colectomy 2005 following perferated colon-septic
•Myopathy
ICD deactivated 2008 following admission with chest infections
Bob 72 yrs old
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Dilated cardiomyopathy with severe left ventricular systolic
dysfunction.
CRTD in 2005 following cardiac arrest
Type II diabetes mellitus.
Chronic kidney disease.
COPD and asbestos exposure in the past.
Depression.
Recent Admissions
• Feb 2012 admitted with COPD
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7th April 2012 admitted with VT, recent chest infection
• 24th April 2012 VT storm and LRTI, psychological distress
• 5 th June PEA arrest? Recent VT
• July 2012 admitted with COPD/heart failure
• August 2012 VT storm and LRTI
Susan 65yrs
Myocardial infarction 1995
LV systolic dysfunction
ICD 1997
February 2012 diagnosed with bowel cancer requiring surgery
May 2012 letter received from GP asking how to deactivate ICD
Patient to come to clinic for discussion re deactivation
Cancelled on day, local HF nurse contacted, to see patient at home. No
HF end of life indicators.
Phone call 4pm Friday from district nurse, why is ICD not deactivated?
Manchester Evening News- 31 May 2013
Eileen Woods' husband Francis was left receiving electric shocks to his
heart for several hours from a ‘zapper’ implant medics didn’t know
how to switch off
Mr Woods, 67, died at home after a short battle with tonsil cancer, but
medics failed to turn off his Implantable Cardioverter Defibrillator
(ICD) for several hours.
An out-of-hours GP came to Mr Woods’ house after he was discharged
with a package of care ….but didn’t know how to deactivate the
device.
Care and Compassion
• Respect patients wishes
• Communicate effectively
• Empathy
• Recognise patient is end of life
• Deactivation is a sensitive issue
• Identify care needs
Summary
• ICD’s are technical devices
• Is resuscitation still appropriate?
• Sensitive communication is important
• Planning is essential
• Painful shocks can be avoided
• Good personalised end of life care is achievable
Thank-you for your attention