A LOOK AT PSYCHOSOCIAL ISSUES POST MI AND WITH ICD
When is deactivation of an implantable cardioverter-defibrillator appropriate? You are listening to ReachMD, The Channel for Medical Professionals. Welcome to The Clinician's Roundtable. I am Susan Dolan, your host, and with me is Dr. Sue A. Thomas, Assistant Dean of the Ph.D. program at the University of Maryland School of Nursing in Baltimore, Maryland.
SUSAN DOLAN:
Dr. Thomas Welcome to The Clinician's Roundtable.
DR. SUE A. THOMAS:
Thank you, I am very excited to be here today and talk about implantable cardioverter-defibrillators.
SUSAN DOLAN:
Give us an implantable cardioverter-defibrillator one-on-one.
DR. SUE A. THOMAS:
Okay, these devices have been around since about the 1970s and at first were rather large devices and now they have gotten smaller. What they do is they help to restore the heart's normal rhythm after the heart has gone into a lethal or deadly rhythm disturbance. So the implantable cardioverter-defibrillator actually gives, monitors the heart's rhythm and gives the heart a short if the heart goes into one of these deadly rhythm disturbances.
SUSAN DOLAN:
How has the technology evolved?
DR. SUE A. THOMAS:
Well they have changed from just being indicated in those patients with lots of frequent rhythm disturbances to now we, since 2005 we have found that these implantable cardioverter-defibrillators can actually increase the survival of patients in heart failure who do not have any lethal heart rhythm disturbances that are detectable.
SUSAN DOLAN:
How does treatment with medications compare to patients who have the implantable devices?
DR. SUE A. THOMAS:
Well, I am going to talk about basically heart failure patients because that has been the latest avenue. With patients who have frequent lethal heart rhythm disturbances, there really are not any really good drugs at this time that will prevent those rhythm disturbances, so a device is really the only answer for patients with rhythm disturbances that are frequent. With heart failure patients, we found in the 2005 sudden cardiac death and heart failure trial, that those patients who were given an implantable cardioverter-defibrillator had a 26% decrease in mortality compared to those patients on drugs, both a placebo drug and the drug amiodarone which is our most successful drug that treats heart rhythm disturbances.
SUSAN DOLAN:
How many ICDs are implanted every year?
DR. SUE A. THOMAS:
Well again with the heart failure population reaching 5 million Americans today. Currently there are about 1 million heart failure patients who are candidates for implanted cardioverter-defibrillators. So it has been a huge growing market and a great change in the outlook for heart failure patients.
SUSAN DOLAN:
Describe the type of education that should occur with implantation.
DR. SUE A. THOMAS:
Well the patients again especially with heart failure, they should know about the shock, with an implanted cardioverter-defibrillator we are monitoring the electrical system of the heart and electromagnetic fields can interrupt the ability to give a shock and to monitor the heart. So what is an electromagnetic field. These are the devices like when you are going in and out of a store, that monitors to see if you have a piece of clothing that you didn’t pay for, that's electromagnetic field. No that field is not dangerous as you walk through it quickly, but if you seen in stores, sometimes there's chairs next to them and patients with an implanted cardioverter-defibrillator should not be sitting near those. They can walk through them, but they can't be sitting there, because that can interfere with their device. The other thing is most risks for these electrical magnetic fields are in hospitals because you're MRI machines and other surgical devices all have these fields, which could interrupt. So any patient going into the hospital with an implanted cardioverter-defibrillator has to make sure that all health care professionals know they have one. What device do have and even if they are visiting other patients, they should make people aware that they this device implanted.
SUSAN DOLAN:
What are the implications for terminally ill patients?
DR. SUE A. THOMAS:
Yes, well heart failure has different stages and I would like to just give you little bit on background on heart failure. There is class 1 heart failure and those patients basically are pretty symptom-free. The symptoms we look for in heart failure are fatigue, palpitations which is irregular heart rhythms, and shortness of breath. So the class 1 is not a candidate for a device. Their symptoms are mild. Class 2 and 3 have more significant symptoms of fatigue. There is irregular heart beating and shortness of breath. Class 2 and 3 are the patients who are candidates for an implanted cardioverter-defibrillator. Class 4 patients have significant symptoms at rest and with any ordinary activity; they have fatigue, palpitations, and shortness of breath. Class 4 is the end-stage of heart failure. Now what happens to patients that we have implanted device in at stage 2 and stage 3 that has progressed to stage 4. Now that’s where you are asking about terminally-ill heart failure patients. Well the American College of Cardiology in the 2005 update for guidelines for the diagnosis and treatment management of chronic heart failure discusses that when patients get end-stage 4 heart failure and that terminal stage of heart failure, that the physician and nurses should initiate a discussion about resuscitation end-of-life procedures and with that discussion, we can find out the patient and family's thoughts and feelings about resuscitation at that stage of their illness and if they do not want to be resuscitated, then we can turn the device off without any surgery and prevent the patient from having the shock occur. Because they have elected not to have end-of-life resuscitation then we would have to turn the implantable cardioverter-defibrillator off.
SUSAN DOLAN:
How is the device turned off?
DR. SUE A. THOMAS:
Actually the doctor can just do it by inserting a small instrument through the skin and you can deactivate it.
SUSAN DOLAN:
If you are just joining us, you are listening to The Clinician's Roundtable from ReachMD.com on XM160, The Channel for Medical Professionals. I am Susan Dolan, your host, and with me is Dr. Sue A. Thomas, Assistant Dean of the Ph.D. program at the University of Maryland School of Nursing in Baltimore, Maryland discussing implantable cardioverter-defibrillators in terminally ill patients.
Dr. Thomas what are practice tips for physicians and healthcare professionals when dealing with end-stage cardiac patients who have implantable devices?
DR. SUE A. THOMAS:
Well most physicians and nurses are comfortable discussing end-of-life decisions with their patients now and what we do is we early on ask patients and their families even before they get to end-of-life what kind of procedures would you want if you were in a terminally ill state and then, of course as their disease progresses, we just have to again update ourselves on are they feeling and thinking they way they did a year ago. Well once a year check on where the patient is about their efforts to resuscitate at end-of-life is about what most nurses and physicians have been practicing.
SUSAN DOLAN:
Is the issue of whether to deactivate appropriate for an ethics committee?
DR. SUE A. THOMAS:
You know, I thought about that and I think that anytime an ethics committee would be involved would be when we had no discussion with patient, we have families who can't decide and then we would ask the ethics committee was it reasonable to turn the device off because the patient would have no chance of survival.
SUSAN DOLAN:
Is deactivation likely to hasten death?
DR. SUE A. THOMAS:
Well you know, in cardiology we always get into this kind of standstill because you can't die until your heart stops and if this device stops you from a sudden cardiac arrest then it could prolong your life unnecessarily, but turning it off just allows nature to take its course.
SUSAN DOLAN:
What is the nurse's role in caring for patients with these devices?
DR. SUE A. THOMAS:
Well again, the nurse is a person who is at the bedside 24 x 7, so her role is to educate the patient and the family about the devices or the dangers of the devices or what the positives of the device and get the patient and family comfortable and conversant about this new technology that is life saving, but they need the education, so they can ask the questions and proceed with their lives without worry about their device.
SUSAN DOLAN:
What resources are available to healthcare professionals who want to learn more about ICDs and end-of-life care?
DR. SUE A. THOMAS:
Well end-of-life-care is a topic that is broadly discussed in most professional journals now, but the end-of-life-care and the ICDs, your most comprehensive resource right now, I think, is the American College of Cardiology 2005 update on guidelines for diagnosis and management of chronic heart failure which really does go into depth about tips on discussing deactivating the implantable cardioverter-defibrillator, the stage in which you would deactivate it and the indications for patients who may want the implantable cardioverter-defibrillator turned off.
SUSAN DOLAN:
Dr. Thomas what is your take-home message?
DR. SUE A. THOMAS:
I think my take-home message is basically that the implanted cardioverter-defibrillators are life-saving devices like all medical therapies. Patients and families must discuss their feelings and thoughts about extending life-sustaining treatment in the face of terminally-ill situation. We need to be able to talk to our patients and families about the view of a peaceful death and with sudden death it is painless and it is peaceful. So those are the kinds of discussions we would have with our patients and allow them to take the option of deactivating their implantable cardioverter-defibrillator when their life is no longer the way they want to live.
SUSAN DOLAN:
Thank you to Dr. Sue A. Thomas who has been our guest discussing implantable cardioverter-defibrillators.
I am Susan Dolan, you have been listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. Please visit our web site at www.reachmd.com which features our entire library through on-demand pod casts or call us toll-free with your comments and suggestions at 888-639-6157. Thank you for listening.
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