End-of-life care

Cardiologists address role of devices in end of life care

A leading cardiologist has called for the creation of national guidelines to assist clinicians in the management of patients with cardiac implantable electronic devices who are nearing the end of life.

Patients who are wearing cardiac devices like pacemakers and defibrillators can sometimes be overlooked, especially if they are chronically ill due to a condition other than cardiac failure, says cardiologist and cardiac electrophysiology specialist Professor Andrew McGavigan.

He wants to see the development and implementation of a national guidance framework for the management of patients with cardiac implantable electronic devices (CIEDs), especially given the fact that there have become commonly used to treat bradyarrhythmias (with pacemakers), and, more recently, for the prevention of sudden cardiac death and treatment of congestive heart failure through use of implantable cardiac defibrillators.

“There is often a misconception that the defibrillator is keeping people alive,” he said. “It’s only in place to be used if it is needed,” says Professor McGavigan who is a Professor of Cardiovascular Medicine at Flinders University.

He told the limbic that patients with advanced, end-stage heart disease were more likely to die from progressive pump failure than sudden cardiac death.

“As you reach end stage heart failure it might be better to turn the defibrillator off,” he said. “I’m not saying that we make these decisions lightly by any shape or form, but we should have the discussion with patients to get people to think about the appropriateness of continuing the use of devices.”

Conversely, he said the decision to turn off a pacemaker is usually enacted in the final days of life. He said he had seen cases where a patient had a DNR order but their devices had not been deactivated.

CIEDs can be easily deactivated without the need for invasive procedures as specialists can “communicate” with the devices wirelessly, usually in a hospital or specialist centre setting.

“Currently we don’t have the facility to deactivate the devices at home, which highlights the importance of discussing deactivating the device early,” Professor McGavigan said.

“When you are having discussions about DNR and advance care planning it’s a good time to talk about the devices. Those decisions are better made when you’re well.”

Professor McGavigan and colleagues from South Australia, Victoria and Brisbane have published a paper in Heart, Lung and Circulation on the consideration of devices in end of life care.

They examined a number of case studies looking at various scenarios, including patients with terminal disease and end-stage heart failure.

“Physicians should be comfortable that ethical and legal considerations potentially allow for patient self-determination of appropriate treatments,” the authors concluded.

“If physicians feel uncomfortable with these decisions they should consider referral to another physician comfortable to provide the management the patient requests.”

While the article provided some framework for guidelines for physicians, Professor McGavigan said there was a clear need for a nationally accepted standard of care.

“With increasing use of CIEDs and an ageing population, the issues at end of life will increasingly affect many healthcare professional,” he said.

“In our opinion, there is a clear need for an Australian-specific set of consensus guidelines.”

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