Thursday, October 02, 2008

End of Life ICD Issues

Anyone dealing of end-of-life issues should review the case study nicely discussed over at Pallimed.

-Wes

5 comments:

Anonymous said...

do you think an ep should be involved with that decision? i mean, what does it mean when they say trials of aad have been unsuccessful? sometimes two work better than one! also, ablation of vt might have solved the problem (palliatively) before it got to this point. of course we all die sometime, but i hate for people to make that decision who don't necessarily know all the options (no offense to anyone meant out there). otoh, i don't want to get called in for an hour long discussion every night at 3 am.

jcmd said...

Morbid question coming. I am a 40 year old with VT and and AICD. Top of the line St. Jude's model implanted about 8 months ago. I am also a physician. My question is this. When it is "my time", what happens to the ICD. I know it can be turned off, but these things are worth 35,000 brand new. Can they be re-used? If they can, I would like for mine to be removed, re-processed and donated to a needy patient. Does that happen? Just wondering as, at that point, I won't really be needing it! Thanks.

DrWes said...

anony 08:02 -

While an EP might add to the discussion some options you propose, once one antiarrhythmic drug (aad) is unsuccessful, addition of other drugs only adds small incremental effectiveness to the patient's arrhythmias. I would assume that the patient's doctors had a good idea about the patient's course. Certainly, VT ablation might have been attempted, but we don't know the other medical issues that might have been in play in this case. The key here is that the doctors had a relationship with the patient and family and we do note that the patient had "end stage heart failure." In cases like these where death appears imminent, then we have to choose which is more "humane" - dying suddenly with an arrhythmia, or dying slowing with congestive heart failure. As you point out, we all die of something eventually. Empowering the patient and family to decide together which is best for them, seems best to me.

jcmd-

I commented on this after my father's death and looked into it. Check out this post. It references an effort underway to offer the service you suggest.

All the best-

Anonymous said...

We had a pt who wanted his ICD turned off once he entered hospice. Our device rep did not feel comfortable going out to the pt's home and deactivating the ICD unless there was an MD present. The pt had to come into the clinic to have his device reprogrammed.

Is there any policy from HRS or the device companies re: this? Was our rep unusual in their request to have the pt come in from his home?

CardioNP

DrWes said...

CardioNP-

It is well known that doctors (especially cardiologists and EPs) turn to device reps to perform many device interrogations and reprogrammings. As such, one could argue this is within the "standard of care." Unfortunately, from a medicolegal standpoint, device reps are to there to sell devices to physicians or hospital systems and are not licensed to perform healthcare.

When reps are asked to re-program a device of any kind (and especially turn off a potentially life-saving therapy) without a license to perform healthcare, they put themselves (and their company) at risk legally. Although it is unfortunate in your patient's case, our medicolegal environment is such that the rep probably made the right choice legally, but maybe not the best choice medically.