ICD Deactivation Current Issues and Raising Awareness- A Device Consultant

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ICD DeactivationCurrent Issues and Raising
Awareness-A Device Consultants Perspective

• Dr Mark Mason
• Harefield Hospital
• Royal Brompton and Harefield NHS Trust

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A new problem generated by an effective solution!

• First implant in 1980
• North West London implant rate in 2005 was around
  80 (for a 1.8 million population)
• SCDHeFT suggested a 22 mortality over 4 years in
  the ICD group (cf. 29 in the placebo arm)
• A significant, and enlarging, group of patients
  will require ICD deactivation as they approach
  end of life

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What are the issues?

• Who?
• Where?
• When?
• Irrevocable?

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What are the issues?

• Who?
• Those for whom reversion of a malignant
  (life-threatening) arrhythmia by the implanted
  device would be deemed inappropriate
• MUST make the distinction between perceived
  impending cardiac death and non-cardiac death

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• Indications for the deactivation of an ICD
• 1. DNAR order in place
• 2. Patient is expected to die within a number of
  days
• 3. Continued activation of ICD is futile in
  management of intractable ventricular arrhythmias
  
• 4. Withdrawal of anti-arrhythmic medications,
  (within the context of a patient nearing the end
  of life where such treatment is now deemed
  inappropriate)
• 5. Use of ICD is inconsistent with planned
  patient care

North West London Cardiac Network Guidelines on
End of Life Issues Surrounding Deactivation of
Implantable Cardioverter Defibrillators (ICDs)
October 2007
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• Indications for the deactivation of an ICD
• DNAR order in place
• Are the two mutually inclusive?
• In general, yes, but it may be appropriate to
  leave the device on in certain circumstances e.g.
  severe heart failure

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• Indications for the deactivation of an ICD
• Patient is expected to die within a number of
  days
• If it is abundantly clear that the patient truly
  is at end of life, then earlier may be
  appropriate

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• Indications for the deactivation of an ICD
• Continued activation of ICD is futile in
  management of intractable ventricular arrhythmias
• ICDs do not cure malignant arrhythmias and
  recurrent therapies may be inappropriate and/or
  distressing to the patient/family

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• Indications for the deactivation of an ICD
• Withdrawal of anti-arrhythmic medications,
  (within the context of a patient nearing the end
  of life where such treatment is now deemed
  inappropriate)
• Clearly IV Rx inappropriate but continuing oral
  therapy may contribute to symptom relief
• (N.B. not all malignant arrhythmias are fatal-
  control of these may form part of symptom relief)

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• Indications for the deactivation of an ICD
• Use of ICD is inconsistent with planned patient
  care
• Probably covered by the preceding slides

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What are the issues?

• Where?
• In elective circumstances, set out in preferred
  place of care (PPC) document
• In urgent/emergency circumstances a strategy is
  in place involving centre/PPC/GP (see local
  guidelines)

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Preferred Place of Care

• Clearly this must be supported
• The support is not just a moral obligation, but
  must be adequately resourced
• There must be recognition that this is
  conventionally performed by cardiac physiologists
  trained to operate in a specific environment

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Preferred Place of Care

• Perhaps the time has come for the development of
  specifically trained individuals and potentially
  drawn from a variety of backgrounds?
• This may (will) require closer liaison between
  local centres and palliative care

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What are the issues?

• When?
• The dialogue should open prior to device implant!
• The therapies should be deactivated as soon as it
  is clear that they would be inappropriate this
  is not necessarily the same as end of life

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What are the issues?

• Irrevocable?
• Distinction may need to be made between cardiac
  and non-cardiac
• The clinical picture may change and, whilst
  device deactivation may be appropriate at a
  certain stage, there may be sufficient
  improvement to merit reinstitution of therapies
• Clearly, this will require sensitive discussion

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Conclusion

• A growing clinical issue
• Must be dealt with proactively
• May require/provide the opportunity for
  imaginative solutions