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Title: Medical Interventions at the End of Life Life Sustaining Treatment and Other Decisions December 12, 2013


1
Medical Interventions at the End of Life Life
Sustaining Treatment and Other Decisions
December 12, 2013
George J. Giokas, MD Director for Palliative
Care, The Community Hospice ggiokas_at_communityhospi
ce.org
2
Topics well cover
  • Trends in End of Life Care
  • Prognostication
  • Communication Establishing goals of care
  • Core Comfort Medicines
  • Noisy Respiratory Secretions Death Rattle
  • Artificial Nutrition and Hydration
  • Implantable Cardiac Electronic Devices


The presenter has no relevant financial
disclosures
3
Learning Objectives
  • At the completion of this webinar the learner
    will be
  • Able to describe the paradigm of benefit,
    effectiveness, and burden of interventions
  • Aware of specialty societies recommendations on
    the use of feeding tubes in patients with
    advanced dementia
  • Able to identify palliative and hospice issues
    in the care of patients with implantable
    cardiovascular devices.

4
A too-common scenario
  • Frail, multiply ill patient
  • Stressed caregiving system
  • Limited social and medical support at
    home
  • Predictable crises at unpredictable times
    CAPC 2013
  • ED utilization ---- Hospitalization ---- ICU
  • Crisis Hospice Referral

5
(No Transcript)
6
(hospice use at least 1 month before death)
7
Increase in ICU utilization prior to death
2000-2009 40 of COPD pts in ICU w/in 1
month of death 22 of dementia patients in
ICU 40 of patients referred to
Hospice w/in 3 days of death had ICU stay that
preceded referral Teno JAMA
2013
20 of ALL deaths in the US occur in the ICU or
shortly after an ICU stay Angus CritCareMed 2004
8
of Medicare Patients with ICU Stay During
Terminal Hospitalization 2007
9


  • 2010 2003-07
  • Dying in Hospital 25
    29
  • Enrolled in Hospice last month of life
    61 55
  • Seeing 10 or more MDs last 6 months
    58 46
  • ICU Admission last month of life
    29 24
  • Hospice Referral last 3 days of life
    11 8
  • Chemo last 2 weeks of life 6
    6
  • LST (vent, FT, CPR) last month of life
    9 9

Medicare patients Analyses controlled for pt
age, sex, race, tumor type and non-cancer chronic
conditions Sept 2013
10
US Adults sampled 1900 interviews Landlines and
cell phones English and Spanish speaking staff
11
http//www.pewforum.org/2013/11/21/views-on-end-of
-life-medical-treatments/
12
End of Life Treatment Challenges
  • The conversation has frequently not occurred
  • Medical Momentum (Default) to Do Something
  • Diagnostic Uncertainty
  • Is this patient actively dying??
  • Multi-factorial - Underlying disease (s) -
    complications treatments/medications
  • Burden of diagnostic and treatment interventions
  • Focus of care patient family ..care
    professionals

13
You got to be very careful if you dont know
where youre going, because you might not get
there.
Yoggi Berra
14
Prognostication
MDs tend to overestimate especially if close
relationship (N Christakos) Clinical
Predictive Rules Walther (hospitalized
patients), Mitchell (NH Dementia), Charlson
(ESRD), Palliative Prognostic Index
e-prognosis.org Estimates of mortality in a
population of patients Cancer patients In later
stages patient-specific characteristics are more
important than tumor-related factors Glare et
al JPM 2008 Common factors performance status,
advanced age, malnutrition, comorbid illness,
increasing organ dysfunction, hospitalization
for acute decompensation (Salpeter,AJM
2011) Would I be surprised if this patient died
in the next year The wavering and uncertain
course for COPD/CHF may explain the frequency of
intensive interventions compared to cancer dxs
(Weissman)
15
Lunney, Lynn, Hogan as cited CanMedAssocJrnl
Aug 2013
16
Advanced Dementia 22 Boston NHs Mitchell, Teno
NEJM Oct 2009
  • 2003 2007 300 residents mean age 85
  • Mean survival was 1.3 years
  • risk of death within 6 months was 25
  • Pneumonia 6 month mortality
    46.7
  • Febrile episode 6 month mortality
    44.5
  • Eating problem 6 month mortality 38.6

17
Mitchell et al JAMA 2004
18
Prognostication Support Study
  • 6 month median survival estimate
  • day prior to death lung cancer 0
  • 5 of 7 days before death for COPD 40
  • Survival to hospital discharge if mech ventilated
  • lung cancer 38
  • COPD 76

Claessens, et al J AM Geriatr Soc 2000 Fried,
et al JAMA Sept 2012
19
Communication Pearls
James Tulsky, MD Duke Univ. Palliative Care
  • Assess the patients preferences for
    communication
  • Ask permission Start with the patients
    agenda
  • Give information in small-chunks Ask-Tell-Ask
  • Track both the emotion and the cognitive data you
    get from the patient
  • Attend to emotion before giving cognitive
    information
  • Articulate empathy explicitly
  • Stay with the patient and move the conversation
    forward one step at a time
  • Less is More

20
Communicating Prognosis
Patients Informational Style ready to hear this?
accompanied by anyone? cultural Communicate
as ballpark rough estimate
ranges days to weeks weeks to months Any
occasions/goals important to patient? Address
Emotion with empathic responses Address
function, care needs, location of care
21
Decision Domains
Benefit the patients assessment of the value of
the treatments result Effectiveness the
physicians determination of the capacity of the
treatment to alter the natural history of the of
the disease Burden the cost, discomfort, and
inconvenience of the treatment physician and
patient E Pellegrino JAMA 2/23/2000
22
What Bothers You Most?
  • Univ of Rochester MC Palliative Care Service
  • 44 Physical Distress
  • pain, dyspnea, anorexia, paresthesias
  • 16 Emotional, spiritual, existential,
    nonspecific distress
  • depression, hopelessness, frustration,
    loneliness
  • Whats the point of all this?
  • 15 Interpersonal Relationships
  • burden to family Missing family activities,
    milestones
  • Family would have to make difficult decisions

Shah, et al, American Journal of Hospice
Palliative Medicine, April/May 2008
23
What Bothers You Most?
  • 15 Dying process Just want to get this over
    with
  • Fear of future physical suffering
  • Sense of not having enough time to do important
    things
  • 12 Loss of function and normalcy
  • Inability to eat and other bodily functions
  • Impossible to continue with work
  • 11 Concern regarding location
  • Not being home Being unable to leave hospital
  • 9 Distress over medical providers or treatment
  • All these different doctors
  • Med side effect I dont like being sleepy

24
ICU Families Difficult Decisions
  • Tensions
  • Responsibility for the loved ones death
  • A chance of recovery
  • Family well-being
  • Coping
  • Recalling prior discussions
  • Sharing decisions with family
  • Delay/defer decisions
  • Spiritual/religious practices
  • Story-telling

Schenker, et al. J Gen Int Med 2012
25
What helps surrogates?
  • Recognize the stress surrogates experience
  • Normalize their stress
  • Facilitate discussions between family members
    with differing views
  • Allow time for decisions
  • Family meeting rooms
  • Time limited trials

Vig, et al Jrnl Pain and Symp Management Nov
2011 Schenker et al J Gen Int Med 2012
26
What helps surrogates?
  • Avoid different information from multiple
    clinicians
  • Receiving recommendations from clinicians
  • Telling them they made the right decision
    afterwards

Vig, et al Jrnl Pain and Symp Management Nov
2011 Schenker et al J Gen Int Med 20121
27
Theyre in DENIAL
  • Too overwhelmed, exhausted to understand
  • Lack of trust
  • Protecting family cultural norms
  • Undertreated anxiety or depression delirium
  • Patients may not understand the prognostic
    information, Language or cultural
    barriers
  • Patients may be confused by differing estimates
    of prognosis
  • Given mixed messages
  • Clinician back-pedals when were
    uncomfortable
  • Denial may be healthy coping

Jacobsen, et al Jrnl Pal Med Jan 2013
28
Do EVERYTHING
Quill, Annals of Internal Medicine, 2009
29
Do EVERYTHING!
  • Acknowledge and follow the patients treatment
    philosophy so that patient / family feel heard
    and respected.
  • Stop regularly discussing DNR or limiting Rxs
    unless this issue is raised by the pt/family or
    change in condition
  • Address discomfort within team
  • Communicate the reasoning behind the treatment
    decision.
  • Find other patient-centered goals (pain,
    dyspnea, support)
  • Time Limited Trials (ICU, dialysis,
    vasopressors)

Quill Annals of Internal Medicine 2009
30
ICU Professional Conflict
  • Conflicts seen by 72 of ICU staff. (2/3 are
    severe).
  • During end-of-life care
  • Lack of psychological support,
  • Absence of staff meetings
  • Problems with decision-making.
  • Am J Resp Crit Care Med 2009180853-60.
    One-day cross-sectional survey of ICU clinicians.
    7,498 ICU staff members (323 ICUs in 24
    countries).

Slide courtesy of Steven Miles, MD Univ of
Minnesota
31
Key Points in End of Life Discussions
  • Is everybody on the same page regarding the
    patients condition prognosis?
  • Focus on GOALS, then recommendations about
    treatments
  • Emphasize what you ARE doing you never stop
    care, you only stop treatments
  • Respect the patient families need for time
    support

Weissman, Quill, Arnold Fast Fact 226
www.mcw.edu/eperc Rosseau Seventy Two Hours
JAMA 2008
32
In truth, reverence for life permeates the care
that I and colleagues in our field provide. .
Reverence for life does not include hastening
death, nor does it include forcing people to
suffer as they die. As a clinician, it does
require me to show up -- with all the resources
and skills my training and experience provide --
and to lean forward, listening to the persons
before me and learning how I can best be of
service.
Ira Byock The Best Care Possible 2012
33
Symptom Management Challenges End of Life
  • Older age (two-thirds are age 65 years or older)
  • Malnutrition, low serum albumin
  • Decreased renal function
  • Autonomic nervous system dysfunction
  • Borderline cognition
  • Lower seizure threshold (metastatic brain
    involvement, use of opioids)
  • Long-term opioid therapy
  • Multiple drug therapy

Up to Date.com
34
4 Essential Drugs
  • 95 palliative care clinicians in 9 countries
  • (UK, Europe, New Zealand, S America)
  • Inpatient palliative care specialists
  • Preferred Rx in last days of life for cancer
    patients
  • anxiety, dyspnea, nausea and vomiting, pain,
    respiratory tract secretions (RTS), terminal
    restlessness.
  • Consensus based, not research based

Lindqvist et al, J Pall Med Jan 2013
35
  • Pain morphine (71)
  • Dyspnea/breathlessness morphine (86)
  • Anxiety midazolam (34) and lorazepam (26)
  • Nausea and vomiting metoclopramide (51) and
    haloperidol (36)
  • RTS hyoscine (hyoscine hydrobromide, hyoscine
    butylbromide 67) and glycopyrronium (25)
  • Terminal restlessness and agitation midazolam
    (40) and haloperidol (36)

Lindqvist et al, J Pall Med Jan 2013
36
South Australian Core Meds
  • Evaluation of the medical literature
  • Cost (govt subsdsidies)
  • Able to address more than one symptom
  • Route(s) of administration
  • Clonazepam
  • Haloperidol
  • Hyoscine butylbromide
  • Metoclopramide
  • Morphine

Tait and Timothy, Journal of Palliative Medicine
July 2013
37
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38
Death Rattle Lokker, et al JPSM June 2013
  • Systematic literature review 1062 articles
  • Bronchial secretion (troubling/noisy/terminal),
    respiratory (tract) secretions, increasing
    secretions, noisy-retained secretions, terminal
    secretions, pulmonary rattles, noisy
    (rattling/moist) breathing (at the end of life),
    or respiratory symptoms - are we studying the
    same process?
  • Occurrence 12 - 92, mean 35.
  • Patients usually unconscious
  • Median time from the onset of death rattle until
    death was between 11 and 28 hours
  • Natural history unknown some placebo trials
    show decrease in death rattle scores over time
    other trials show increase over time
  • The symptom is not resolved in 2250 of cases

39
  • In a study among nurses, 87 indicated that they
    felt that death rattle does not distress the
    dying patient.
  • But may distress the other patients on the ward
  • Distress as reported by relatives on themselves
  • 5 not so distressing
  • 15 slightly distressing
  • 26 distressing
  • 52 very distressing
  • 79 of nurses reported distress to themselves

40
Family Perceptions Shimizu, et al JPSM December
2013
  • 103 Palliative Care Units in Japan pts died in
    PCU
  • 663 questionnaires mailed to bereaved family with
    390 (61) response rate
  • 181 (46) respondents experienced death rattle.
  • Of these, 66 of reported high distress levels to
    themselves
  • 53 perceived a strong need for improved death
    rattle care
  • Factors influencing high distress
  • unawareness about death rattle being a natural
    phenomenon,
  • distressing interpretations of death rattle
    drowning, suffocating
  • 50 of family members not educated about death
    rattle

41
Anticholinergic Load and RTS
  • Acetyl choline major neurotransmitter in both
    central, peripheral nervous system, organs, and
    muscle
  • Cholinergic effects sweating, salivary
    production, diarrhea, bladder emptying, slow
    heart rate
  • Anticholinergic effects lack of sweating, dry
    mouth, constipation, urinary retention, blurred
    vision, confusion, delirium, rapid heart rate
  • Commonly used anticholinergics
  • Atropine drops, Transdermal scopalamine patch
  • Hyoscyamine (Levsin)
  • Glycopyrrolate (Robinol)

42
Sheehan Journal of Palliative Medicine 2011
43
Death Rattle Is Not Associated with Patient
Respiratory Distress Is Pharmacologic Treatment
Indicated? Campbell and Yarandi JPM 2013
  • Prospective observational study - 71 terminal
    pts 3 inpatient palliative care and hospice
    units
  • Death Rattle Intensity Scale (volume) and degree
    of respiratory distress .heart rate resp rate,
    accessory muscle use restlessness grunting at
    end of expiration nasal flaring and fearful
    facial expression
  • There was no association between intensity of
    death rattle and respiratory distress
  • Infrequent use of anti-secretory meds when used
    had limited effectiveness

44
  • Thus, it remains counterintuitive to prescribe
    medications with limited effectiveness in the
    face of no patient distress.
  • Campbell and Yarandi JPM 2013
  • No evidence to show that any intervention, be
    it pharmacological or non-pharmacological, was
    superior to placebo in the treatment of noisy
    breathing.
  • Wee B, Hillier R, The Cochrane Collaboration,
    2012

45
  • Current evidence does not support
  • the standard use of (anticholinergic) drugs
  • in the treatment of death rattle. care should
    focus on communication about the symptom with
    relatives and others involved in the care of
    these patients.
  • Regarding the symptom as being part of the
    normal dying process could contribute to the
    lowering of distress levels of those involved.

Lokker, et al JPSM June 2013
46
  • Provision of good oral hygiene nursing care,
    including managing uncomfortable smells.
  • Consulting with family members about suctioning
  • Providing frequent explanations that death rattle
    is a natural phenomenon
  • Understanding familys interpretations and
    feelings regarding death rattle and providing
    emotional support

Shimizu, JPSM Dec 2013
47
Summary
  • Lack of clinical evidence supporting drug Rx
  • Potential for significant harm of drug Rx
  • Educate families and nursing/MD staff
  • IF you feel compelled to Rx with medications
  • Avoid transdermal during last days
  • Avoid co-administration of multiple agents
  • Consider glycopyrrolate
  • Do research and publish a study!

48
(No Transcript)
49
AMERICAN GERIATRICS SOCIETY Feeding Tubes in
Advanced Dementia Position Statement May 2013
  • Percutaneous feeding tubes are not recommended
    for older adults with advanced dementia. Careful
    hand-feeding should be offered for persons with
    advanced dementia, hand feeding is at least as
    good as tube-feeding for the outcomes of death,
    aspiration pneumonia, functional status and
    patient comfort. Tube feeding is associated with
    agitation, increased use of physical and chemical
    restraints, and worsening pressure ulcers.
  • Efforts to enhance oral feeding by altering the
    environment and creating patient-centered
    approaches to feeding should be part of usual
    care for older adults with advanced dementia.
  • Older adults with advanced dementia are
    bed-bound, unable to ambulate, and have limited,
    if any, ability to communicate verbally.

50
  • 3. Tube feeding is a medical therapy that can be
    declined or accepted by a patients surrogate
    decision maker in accordance with advance
    directives, previously stated wishes, or what it
    is thought the patient would want.
  • 4. It is the responsibility of all members of the
    health care team caring for residents in longterm
    care settings to understand any previously
    expressed wishes of the patient (through review
    of advance directives and with surrogate
    caregivers) regarding tube feeding and
    incorporate these wishes into the care plan.
  • 5. Institutions such as hospitals, nursing homes
    and other care settings should promote choice,
    endorse shared and informed decision-making, and
    honor patient preferences regarding tube feeding.
    They should not impose obligations or exert
    pressure on patients or providers to institute
    tube feeding

51
Benefits and Burdens of PEG Placement
Quality Collaborative Monroe County Medical
Society Oct 2010 www.compassionandsupport.org
52

  Starvation Cachexia
Appetite Suppressed in late phase Suppressed in early phase
Body mass index Not predictive of mortality Predictive of mortality
Serum albumin Low in late phase Low in early phase
Cholesterol May remain normal Low
Total lymphocyte count Low, responds to refeeding Low, unresponsive to refeeding
Cytokines Little data Elevated
Inflammatory disease Usually not present Present
Response to refeeding Reversible Resistant
Thomas, D Clinics in Geriatric Medicine, 2002
53
Dont recommend percutaneous feeding tubes in
patients with advanced dementia instead, offer
oral assisted feeding. In advanced dementia,
studies have found feeding tubes do not result in
improved survival, prevention of aspiration
pneumonia, or improved healing of pressure
ulcers. Feeding tube use in such patients has
actually been associated with pressure ulcer
development, use of physical and pharmacological
restraints, and patient distress about the tube
itself. Assistance with oral feeding is an
evidence-based approach to provide nutrition for
patients with advanced dementia and feeding
problems in the final phase of this disease,
assisted feeding may focus on comfort and human
interaction more than nutritional goals.
54
Dont recommend percutaneous feeding tubes in
patients with advanced dementia instead offer
oral assisted feeding. Careful hand-feeding for
patients with severe dementia is at least as good
as tube-feeding for the outcomes of death,
aspiration pneumonia, functional status and
patient comfort. Food is the preferred nutrient.
Tube-feeding is associated with agitation,
increased use of physical and chemical restraints
and worsening pressure ulcers.
55
Dont insert percutaneous feeding tubes in
individuals with advanced dementia. Instead,
offer oral assisted feedings. Strong evidence
exists that artificial nutrition does not prolong
life or improve quality of life in patients with
advanced dementia. Substantial functional decline
and recurrent or progressive medical illnesses
may indicate that a patient who is not eating is
unlikely to obtain any significant or
long-term benefit from artificial nutrition.
Feeding tubes are often placed after
hospitalization, frequently with concerns for
aspirations, and for those who are not eating.
Contrary to what many people think, tube feeding
does not ensure the patients comfort or reduce
suffering it may cause fluid overload, diarrhea,
abdominal pain, local complications, less human
interaction and may increase the risk of
aspiration. Assistance with oral feeding is
an evidence-based approach to provide nutrition
for patients with advanced dementia and feeding
problems.
http//www.choosingwisely.org/wp-content/uploads/2
013/09/AMDA-5things-List_Final.pdf
56
Teno JM, Gozalo PL, Mitchell SL, Kuo S, Rhodes
RL, Bynum JP, Mor V. Does feeding tube insertion
and its timing improve survival? J Am Geriatr
Soc. 2012 Oct60(10)1918-21. Hanson LC, Ersek
M, Gilliam R, Carey TS. Oral feeding options for
people with dementia a systematic review. J Am
Geriatr Soc. 201159(3)463-72. Palecek EJ, Teno
JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell
SL. Comfort feeding only a proposal to bring
clarity to decision-making regarding difficulty
with eating for persons with advanced dementia. J
Am Geriatr Soc. 201058(3)580-4. Sorrell JM.
Use of feeding tubes in patients with advanced
dementia are we doing harm? J Psychosoc Nurs
Ment Health Serv. 2010 May48(5)15-8. Sampson
EL, Candy B, Jones L. Enteral tube feeding for
older people with advanced dementia. Cochrane
Database Syst Rev. 2009 Apr 15(2)CD007209. Gill
ick MR, Volandes AE. The standard of caring why
do we still use feeding tubes in patients with
advanced dementia? J Am Med Dir Assoc. 2008
Jun9(5)364-7. Ganzini L. Artificial nutrition
and hydration at the end of life ethics and
evidence. Palliat Support Care. 2006
Jun4(2)135-43. Li I. Feeding tubes in patients
with severe dementia. Am Fam Physician. 2002 Apr
1565(8)1605-11. Finucane TE, Christmas C,
Travis K. Tube feeding in patients with advanced
dementia a review of the evidence. JAMA. 1999
Oct 13282(14)1365-70. Mitchell SL, Kiely DK,
Lipsitz LA. The risk factors and impact on
survival of feeding tube placement in nursing
home residents with severe cognitive impairment.
Arch Intern Med. 1997 Feb 10157(3)327-32.
http//www.choosingwisely.org/wp-content/uploads/2
013/09/AMDA-5things-List_Final.pdf
57
  • It is easy to lose sight of the fact that not
    eating may be one of the many facets of the dying
    process and not the cause

Robert McCann, JAMA Oct 13, 1999
58
Strategies for Family Care
  • Relieving Family Members Sense of Helplessness
    and Guilt
  • I know you did everything
  • Providing Appropriate Information About Hydration
    and Nutrition at End of Life
  • Providing Emotional Support for Family Members
    Concerns
  • Attention to the Patients Symptoms

Yamagishi, JPSM, 2010
59
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60
Cardiovascular implantable electronic devices
  • Hundreds of thousands of US patients have
    pacemakers (PMs) and implantable
    cardioverter-defibrillators(ICDs) approx 100,000
    ICDs/year alone
  • Pacemakers protect against bradycardia (too slow)
    lightheadedness, fatigue, fainting
    0.5 joules
  • ICDs deliver high energy shock to interrupt a
    tacchycardia (too fast) heart rhythm to prevent
    sudden death 15 40 joules
  • ED/EMT Transthoracic Defibrillation Stand
    Clear!! 100-150 joules
  • Many dying patients with ICDs experience shocks
    as they approach death hospice survey.. 58
    reported pt receiving a shock from ICD
  • Advance Directives rarely mention devices

Buchhalter JAMA Internal Medicine Nov 2013
61
Cardiovascular implantable electronic device
(ICD) deactivation Buchhalter et al JAMA Int
Med Nov 25, 2013
  • Retrospective review of 150 patients at Mayo
    Clinic, Rochester, Minnesota
  • Nov 2008 Dec 2012 (approx 3 deactivation per
    month)
  • Median age, 79 years 67 male, 99 had poor or
    terminal prognoses.
  • Half of the deactivation requests were made by
    surrogates.

62
Deactivation of ICDs and PMs
  • 90 died w/in 1 month
  • Median survival 0-3 days 3 alive at 1 year
  • Causes of death
  • cardiovascular disease (71 patients)
  • neurologic disease (19), cancer (18),
  • MOSF (13), respiratory disease (10) and other
    (15)
  • Reasons for requests
  • Avoid shocks during dying process
  • Avoid device interfering with a natural death
  • 43 palliative medicine consultation
  • 2 ethics consultations

Buchhalter JAMA Internal Medicine Nov 2013
63
Deactivation of ICDs and PMs
  • 2 MD refusals - both pacer dependent patients
  • Guidelines (Heart Rhythm Society Insitutional)
    Provider conscientious objection
  • Patients right to transfer care
  • 3 Ethics Consults
  • intra-family conflict
  • inconsistent EOL request by patient
  • AD differing from surrogate request

http//archinte.jamanetwork.com/multimedia.aspx
64
Patient Survey - ICDs
Dodson et al JAMA Int Med March 2013
  • ICD patients 50 yrs and older _at_ Yale University
    EP practice Jan 2006 Dec 2009
  • 136 eligible patients 95 (70) agreed to
    participate.
  • Mean age was 71 years 28 F 19 nonwhite.
  • Mean duration of ICD placement was 4.0 years
  • 29 had received a prior ICD shock.
  • 31 reported unknown or no benefits of
    their ICD
  • Other responses (number)
  • restarting the heart (31)
  • living longer (27)
  • improving quality of life (7),
  • 3 patients thought the ICD prevented Afib/
    stroke
  • 60 participants could not name a potential harm

65
Dodson et al JAMA Int Med March 2013
66
Dodson et al JAMA Int Med March 2013
67
  • Participants were then read a standardized script
    providing the best current evidence regarding
    benefits and burdens of ICDs. Then . asked
  • Would you want your ICD deactivated if
  • Permanently unable to get out of bed
  • Permanent memory problems
  • Burden to family members
  • Prolonged mechanical ventilation (1 month)
  • Advanced incurable disease.
  • 5 point scale Definitely No .Definitely yes
  • 71 responded Probably yes or Definitely yes to
    at least 1 scenario 61 adv incurable
    24 unable to get OOB

Dodson et al JAMA Int Med March 2013
68
Dodson et al JAMA Int Med March 2013
69
Dont leave an implantable cardioverter-defibrilla
tor (ICD) activated when it is inconsistent with
the patient/family goals of care. In about a
quarter of patients with ICDs, the defibrillator
fires within weeks preceding death. For patients
with advanced irreversible diseases, defibrillator
shocks rarely prevent death, may be painful to
patients and are distressing to caregivers/family
members. Currently there are no formal practice
protocols to address deactivation fewer than 10
of hospices have official policies. Advance care
planning discussions should include the option of
deactivating the ICD when it no longer supports
the patients goals.
70
Recommendations
  • Patient education needed regarding benefits/risks
  • Upfront discussions re prognosis / goals / ADs
  • Implantation/ Generator Change/Med Condition
  • Role for palliative care
  • No longer considered life-long therapy
  • Address deactivation on admission to hospice and
    EOL discussions AND / avoid shocks vs
    deactivating a device
  • Does your Hospice have a policy? Annals of Int
    Medicine 2010
  • survey of 900 hospices 414 responded
  • 97 of hospices admitted patients with ICDs
  • 42 of patients with ICDs had the shocking
    function deactivated.
  • Only 10 of hospices had a policy that addressed
    deactivation
  • http//aging.stanford.edu/2013/11/story-jerry-roma
    no/

71
Selected References and Resources
  • Smith, A. et al. Half Of Older Americans Seen In
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