Pacemakers, Defibrillators and (Im)mortality.

Pacemakers, Defibrillators and (Im)mortality.

Cardiac Implantable Electronic Devices (CIEDs – a cover-all term for permanent pacemakers and implantable defibrillators) are becoming increasingly common in the population as a whole and therefore are becoming increasingly encountered by health professionals delivering End-of-Life (EoL) care. This can result in ethical dilemmas around switching off or modifying the therapies delivered by these devices.

There’s a very interesting article  with  2 accompanying editorials in this month’s JAMA Internal Medicine (the journal formerly known as Archives of Internal Medicine) looking at the potentially thorny issues around de-activating CIEDs.  All are free, open access.

The article, by Buchhalter et al,  is a retrospective chart review covering a 4 year period from 2008-2012 and looking at all patients who had a CIED deactivated at the Mayo Clinic in Minnesota.

Of note:

  • 159 requests for deactivation
  • 9 requests not carried out
  • 2 of the non deactivations were physician refusals (I found this particularly interesting).  In both cases the patient had a PPM and requested that it be turned off, which is a slightly different issue compared with turning off an ICD.  In one case the physician requested an ethics consult but the patient died before it could be arranged.  In the second case the physician refused to deactivate the device but referred the patient to another physician.  Again the patient died before the consult took place.
  • Of the remaining 150 patients who underwent device deactivation, 99% had a terminal prognosis (the one patient who didn’t was getting inappropriate shocks from an ICD)
  • Most of the patients had an ICD and only had tachycardia therapies stopped.  Some of them also had bradycardia therapies deactivated.  A small number of the patients were pacemaker dependant and had bradycardia therapies deactivated.
  • Half of the requests were from patients and half from surrogate decision makers (SDMs)
  • 57% of the patients had an advanced directive, but only one of them mentioned the CIED!
  • 27% of patients who had tachycardia therapies deactivated died within a day of deactivation, 71% within a week, 87% within a month.
  • Of those who also had bradycardia therapies switched off, 53% died within a day, 88% within a week.

The authors mention in the discussion that most of the requests were for deactivation of tachycardia therapies in order to avoid uncomfortable shocks at the end of life.  From an ethical standpoint, deactivating an ICD to me seems no different to being documented as Not-for-Resuscitation.  Deactivating a PPM, particularly in a pacemaker dependant patient probably requires a bit more discussion with patients and SDMs, but again would seem to me to fall under the umbrella of withdrawing life-sustaining treatment as opposed to actively ending someone’s life.

The first accompanying editorial by Butler and Puri was a better read, and a bit more emotive.  It begins;

As he lay dying in a hospital in San Diego, a 71-year-old retired commercial fisherman was shocked 10 times by his implantable cardioverter-defibrillator (ICD), convulsing in front of his wife, 7 children, siblings, and mother. For 2 days, no medical professional intervened. The device was deactivated only at his wife’s insistence. Afterwards, she wanted to know, “Why wasn’t there a sticker on his chart? Why didn’t someone write that order?”

The editorialists go on to discuss the issue of the increasing number of devices being implanted and how these might impact on EoL care.  They neatly sum up fragmentation of medical care (a problem encountered daily by intensivists, palliative medicine specialists, geriatrician and the few other generalists who happen to be left in the super-specialized hospital of the 21st century) and highlight the important of interprofessional communication.

The authors mention that only in 2010 did the Heart Rhythm Society state in  a guideline that it was “ethically permissible” to deactiviate a device, and they wonder when anyone will state that it should be an “ethical responsibility” to inform patients that deactivation is an option.  The authors conclude by postulating a way forward that involves increased training in communication skills and increased collaboration between cardiology and palliative medicine – a trend that is already occurring in many places.

One of the authors of the editorial, Katy Butler, has previously written on this issue from a very personal perspective in a New York Times Magazine article entitled “What Broke my Father’s Heart.”   This article was quite moving and well worth a read.  It’s always good to look at the health system from the perspective of a non-clinician, and Butler, a writer and teacher, does this eloquently and in a balanced manner.

Finally, in a really quite moving and inspirational editorial,  Matlock and Mandrola highlight the fact that delivering caring end of life care is just good medicine and that early communication with patients is the key to preventing many issues and suffering that may result from conflicts at the end of life.   With a couple of simple, to-the-point quotes they sum up the issue;

  • CIEDs do not confer immortality.
  • Death is not optional.
  • Deactivating a pacemaker in a pacemaker-dependent patient is no different than withdrawing a ventilator from a ventilator-dependent patient.

All 4 articles are thought-provoking, well worth a read and eminently relevant to those working in critical care or, indeed, any aspect of acute medicine.

Nurse! Fetch the Nikethamide and the Lobeline!

I’ve just had a most enjoyable day wasting a lot of time while watching some pretty amazing videos on youtube.  I’m a big fan of medical history, particularly the history of resuscitation and intensive care.  The Wellcome trust from UK have a cornucopia of videos available and in addition to being a fascinating look at our past, some of them are just downright hilarious.

My favourite thus far is “Respiratory and Cardiac Arrest” from 1945.  It’s aimed at junior doctors delivering general anaesthesia. Some interesting techniques include;

– Mouth to mouth in theatre

–  If trismus is present, wait until the the patient is just about dead, then force a Guedel airway in and start ventilating.

– Internal massage (from the upper abdomen) and intracardiac adrenaline routinely

And of course there are some brilliant quotes, Like;

“If an endotracheal tube is immediately available, intubate the trachea.  But don’t waste time looking for one.”

– (After ROSC) “Accompany the patient back to the ward yourself, with supplemental oxygen if it’s practicable.”

There were a couple of drugs mentioned that I hadn’t heard of:

– Nikethamide: Respiratory stimulant

– Lobeline: Sympathomimetic (increased dopamine release, decreased reuptake of dopamine and serotonin

We really have come a long way in a short time.

Among the other videos that I’ve stumbled upon there is one of what looks like one of my all time favourite moments in medical history – the MacIntosh/Pask Mae-West lifejacket tests.

To cut a long story short, during the war (I know we shouldn’t mention it), lots of airmen were dying after bailing out of their aircraft because once inflated, their life jackets would float them face down.  So the RAF turned to 2 men who, like Sir Kieth Park and Alan Turing, were great unsung (and unheard of) heroes of WWII: Grp Cpt Sir Robert MacIntosh (of Timaru, no less) and Wng Cdr Edgar Pask.  Two anaesthetists from Oxford with an interest in aviation, and war-winning.  MacIntosh of course, was the first professor of anaesthesia in the UK and is immortalized in the name of the most popular laryngoscope blade, which he developed.

MacIntosh and Pask rose the task of lifejacket development the only way that made sense – by anaesthetising Pask and throwing him in the pool while different designs were tested until one was found the would allow him to float face up.  This excellent article from the Royal Army Medical Corps Journal sums it all up nicel, as does Maltby’s excellent little book “Notable Names in Anaesthesia.” Pask got a PhD for this, which he famously joked that he was asleep for most of.  It’s unassuming, humble characters like this that make medicine such a great profession, not the Dr. Oz’s and the like of today.  I hope I can be a little like MacItosh or Pask one day.  However I don’t like the idea of being dunked in the pool while anaesthetised.  It would probably be better than HUET though….

Would you like a slice of cheescake with your septic shock?

Here’s a really interesting article written by American rockstar surgeon Atul Gawande (you must go and read all of his books at once).  He compares the healthcare system to the large US restaurant chain The Cheesecake Factory (go there the next time you’re in US, it’s pretty cool).  As usual he makes some very good points.