Over the past decade, there has been a significant increase in the use of Automatic Implantable Cardioverter Defibrillators (AICDs). An AICD is a device that uses electrical pulses or shocks to control life-threatening arrhythmias. Terminally ill patients face the risk of AICD shocks during the dying process, which may be inconsistent with the hospice patient’s wishes and cause significant distress to both patients and caregivers. This was highlighted by NBC News in a story that aired recently, called “Defibrillator Implants Can Interfere with Peaceful Death.”
The role of the hospice agency for patients with AICDs is first to identify the presence of such a device. If there is one, ask for the ICD card/leaflet. If the card or pamphlet is unavailable, the name of their Cardiologist may help. The card should have the details for the AICD manufacturer.
The most common manufacturers are:
Boston Scientific 800-227-3422
Medtronic 800-633-8766
St. Jude Medical 800-681-9293
Ethical and legal factors surrounding AICDs at the end of life are similar to other issues such as DNR orders. These factors should be considered to assist open and sensitive communication with patients and families regarding prognosis and plan of care. The possibility of AICD discharge during the dying process should be clearly explained as soon as possible during the admission process and reinforced throughout the hospice stay. The Heart Rhythm Society has published a handout (see End of Life Heart Rhythm Devices) that may be useful in answering questions that patients/families and your hospice team may have. The possibility of AICD deactivation should be explored.
Triggers that may indicate necessity to initiate or reinforce a conversation related to deactivation throughout the hospice stay may include presence of a DNR, deteriorating quality of life, refractory symptoms despite optimal therapy, withdrawal of anti-arrhythmic medications related to a decline in the trajectory of the illness and comorbidities with a poor prognosis.
Whether or not the patient wants deactivation, documentation of the discussion and goals should be available in the clinical record.
If the patient chooses deactivation, obtain the physician’s order and contact the Cardiac Physiologist or manufacturer for assistance.
Planned deactivation is done by placing a small device over the implant site, is done in minutes and is painless. It does not require a further procedure after death. It is also reversible if the patient’s terminal condition improves.
Emergency deactivation can be done by any healthcare professional by placing a special magnet directly over the implant site (usually a bump on the left side of the chest below the collar bone), and taping it in place. It prevents the AICD from delivering a shock. This is temporary and the AICD will return to normal function when the magnet is removed. The hospice agency can ask for magnets from the manufacturers. These are normally free of charge. The device should not be removed and will still require deactivation after death unless otherwise instructed by the manufacturer. The magnet is safe for all staff to use.
After death, the funeral home may remove the AICD prior to cremation or burial. The hospice may be asked to notify the manufacturer where the body will be and should notify the funeral home of the AICD status (whether or not it has been turned off).
Agency policies and procedures should address agency philosophy for deactivation of defibrillators.