Deactivation of ICD’s in End of Life CarePresented by Sister Sarah CollittElectrophysiologist 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?

• 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

•refractory symptoms •three hospital admissions in less than six months•experience multiple shocks from their device•comorbidity •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• 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• 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