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Newcomer K, Godfrey S, Kumar S, Lorusso N, Patel N, Garrett B, Chen C, Sulistio MS. Increasing Knowledge about Implantable Cardioverter Defibrillators at the End of Life, an Effective Approach for Hospice Workers to Improve Patient Care. J Pain Symptom Manage 2024; 67:e409-e415. [PMID: 38331233 DOI: 10.1016/j.jpainsymman.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICDs) decrease mortality in high-risk patients but can also cause distressing shocks near death. Patients who lack knowledge about their ICDs are more likely to have an active device at the end of life. Many hospice workers lack sufficient knowledge to educate patients about ICDs. MEASURES An ICD educational video created for use in a diverse, underserved patient population was shown to hospice workers from two large community hospices and attendees of a regional conference. A validated 10 question survey was given to participants before and after the video. OUTCOMES Significant improvement in ICD knowledge scores was seen in all participants (W = 3119.5, P < 0.0001). While doctors and nurses showed higher pretest knowledge, post-test knowledge scores equalized across all participants. CONCLUSIONS/LESSONS LEARNED An ICD patient educational video designed for a diverse, underserved patient population effectively improved ICD knowledge to a uniform excellent level for a broad range of hospice workers.
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Affiliation(s)
- Kelley Newcomer
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah Godfrey
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharika Kumar
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Nakul Patel
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brenden Garrett
- University of Texas Southwestern Medical Center, Dallas, Texas
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Callaghan EM, Diamandis-Nikoletatos E, van Leeuwen PP, Higgins JB, Somerville CE, Brown LJ, Schumacher TL. Communication regarding the deactivation of implantable cardioverter-defibrillators: A scoping review and narrative summary of current interventions. PATIENT EDUCATION AND COUNSELING 2022; 105:3431-3445. [PMID: 36055906 DOI: 10.1016/j.pec.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Communication about deactivation of implantable cardioverter-defibrillator (ICD) therapy at end-of-life (EoL) is a recognised issue within clinical practice. The aim of this scoping review was to explore and map the current literature in this field, with a focus on papers which implemented interventional studies. METHODS Systematic searches of six major databases were conducted. Citations were included by four researchers according to selection criteria. Key demographic data and prespecified themes in relation to communication of ICD deactivation at EoL were extracted. RESULTS The search found 6197 texts of which 63 were included: 39 quantitative, 14 qualitative and 10 mixed-methods. Surveys were predominantly used to gather data (n = 34), followed by interviews (n = 18) and retrospective reviews of patient records (n = 18). CONCLUSIONS Several key gaps in the literature warrant further research. These include who is responsible for initiating ICD deactivation discussions, how clinicians should initiate and conduct these discussions, when ICD deactivations should be occurring, and family perspectives. Adequately explored themes include patient and clinician knowledge and attitudes regarding ICD deactivation at EoL. PRACTICAL IMPLICATIONS Facilities treating patients with ICDs at EoL should consider ongoing quality improvement projects aimed at clinician education and protocol changes to improve communication surrounding EoL ICD deactivation.
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Affiliation(s)
- Ellen M Callaghan
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Elly Diamandis-Nikoletatos
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Paul P van Leeuwen
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | - Jack B Higgins
- School of Medicine and Public Health (Joint Medical Program), University of Newcastle, Callaghan, NSW 2305, Australia; School of Rural Medicine (Joint Medical Program), University of New England, Armidale, NSW 2350, Australia
| | | | - Leanne J Brown
- Department of Rural Health, College of Health, Medicine and Wellbeing, University of Newcastle, Tamworth, NSW 2340, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia
| | - Tracy L Schumacher
- Department of Rural Health, College of Health, Medicine and Wellbeing, University of Newcastle, Tamworth, NSW 2340, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
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Mosoiu D, Rogozea L, Landon A, Bisoc A, Tint D. Palliative Care in Heart Failure: A Public Health Emergency. Am J Ther 2020; 27:e204-e223. [PMID: 31688067 DOI: 10.1097/mjt.0000000000001067] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Palliative care (PC) is the holistic care of patients with life-limiting illnesses focused on relief of suffering and maximizing quality of life for patients and their families. Patients with heart failure (HF) are the largest group eligible for PC services, but only a small percentage of them receive PC. AREAS OF UNCERTAINTY The optimal content and method of delivery of PC interventions to HF patients in resource-limited countries remain unknown. The integration of PC into existing HF disease management continues to be a challenge. DATA SOURCES PUBMED was searched to identify articles on the topic published in the last 5 years (2014-April 2019). One hundred thirty-six articles were identified-14 articles out of were included in the revision. THERAPEUTIC ADVANCES Research concerning PC in HF is still scarce and comes predominantly from developed countries. PC in HF improves patients' and caregivers' outcomes in terms of dyspnea, sleep, depression, communication, coping, and care-giving burden. Specialized home-based PC services have a positive impact on patients' physical and emotional wellbeing while decreasing utilization of medical services. Fatigue, dyspnea, and pain are frequent symptoms. Evidence concerning use of opioids for dyspnea is increasing. Family caregivers offer a considerable amount of care during the disease trajectory. There is often incongruence between the carer's and the patient's wishes in terms of treatment decisions and preferences. Carers should be assessed for risk and supported in their roles in care management and care coordination. CONCLUSIONS Because of the unpredictability of the disease and difficulty in prognostication, PC should be introduced at the point of diagnosis of HF. Basic education in PC needs to be introduced early in the training of cardiology staff, focused on concept definition, differencing PC and terminal care, symptom management, communication, and decision-making.
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Affiliation(s)
- Daniela Mosoiu
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania.,Education and National Development Department, Hospice Casa Sperantei, Brasov, Romania
| | - Liliana Rogozea
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania
| | | | - Alina Bisoc
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania.,Emergency County Clinical Hospital, Brasov, Romania; and
| | - Diana Tint
- Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania.,ICCO Clinics, Brasov, Romania
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"Why Would I Choose Death?": A Qualitative Study of Patient Understanding of the Role and Limitations of Cardiac Devices. J Cardiovasc Nurs 2020; 34:275-282. [PMID: 30789490 DOI: 10.1097/jcn.0000000000000565] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Although cardiology organizations recommend early introduction of palliative care for patients with heart failure (HF), integration has remained challenging, particularly in patients with cardiac devices such as cardiac implantable electronic devices and left ventricular assist devices. Study authors suggest that patients often have limited and erroneous understanding of these devices and their implications for future care. OBJECTIVE The aim of this study was to assess perceptions of cardiac devices in patients with HF and how these perceptions impacted advance care planning and future expectations. METHODS This study used qualitative semistructured interviews with 18 community-dwelling patients with New York Heart Association stage II to IV HF. RESULTS We interviewed 18 patients (mean ejection fraction, 38%; mean age, 64 years; 33% female; 83% white; 39% New York Heart Association class II, 39% class III, and 22% class IV). All had a cardiac implantable electronic device (6% permanent pacemaker, 56% implantable cardioverter-defibrillator, 28% biventricular implantable cardioverter-defibrillator); 11% had left ventricular assist devices. Patients with devices frequently misunderstood the impact of their device on cardiac function. A majority expressed the belief that the device would forestall further deterioration, regardless of whether this was the case. This anticipation of stability was often accompanied by the expectation that emerging technologies would continue to preempt decline. Citing this faith in technology, these patients frequently saw limited value in advance care planning. CONCLUSIONS In our sample, patients with cardiac devices overestimated the impact of their devices on preventing disease progression and death and deprioritized advance care planning as a result.
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Tischer T, Bebersdorf A, Albrecht C, Manhart J, Büttner A, Öner A, Safak E, Ince H, Ortak J, Caglayan E. Deactivation of cardiovascular implantable electronic devices in patients nearing end of life : Reality or only recommendation? Herz 2019; 45:123-129. [PMID: 31312871 DOI: 10.1007/s00059-019-4836-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/23/2019] [Accepted: 06/21/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Current guidelines recommend considering deactivation of cardiac implantable electronic devices (CIEDs) in patients nearing death. We evaluated the implementation of this recommendation in unselected deceased individuals with CIEDs. METHODS Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for CIEDs and these were interrogated in situ. Pacing rate, pacing mode, and lead output were documented as well as patient data including location and time of death. In implantable cardioverter-defibrillators (ICDs), tachycardia therapy adjustment and occurrence of shocks 24 h prior to death were also recorded. RESULTS We examined 2297 subjects, of whom 154 (6.7%) had CIEDs. Of these subjects, 125 (100%) pacemakers (PMs) and 27 (96.4%) ICDs were eligible for analysis. Death in persons with ICDs occurred most frequently in hospital (55.6%), while this was less frequently the case for individuals with PMs (43.2%). Furthermore, 33.3% of subjects with ICDs and 18.5% with PMs died in palliative care units (PCU). Shock therapies were switched off in three (60%) individuals with ICDs who died in the PCU, whereas antibradycardia therapy was not withdrawn in any PM patient in the PCU. Therapy withdrawal occurred in two patients with PMs (1.3%) who died in hospital. Patients with PMs had high ventricular pacing rates at the last interrogation (69 ± 36.0%) and often suffered atrioventricular block (39.2%). Six (25%) of the 24 active ICDs presented shocks near the time of death. CONCLUSION Many CIED patients died in hospital; nonetheless, in practice, CIED deactivation near death is rarely performed and might be less feasible in subjects with PMs. However, there is still a need to consider deactivation, especially in individuals with ICDs, as one fourth of them received at least one shock within 24 h prior to death.
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Affiliation(s)
- T Tischer
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
| | - A Bebersdorf
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - C Albrecht
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - J Manhart
- Institute of Legal Medicine, Rostock University Medical Center, Rostock, Germany
| | - A Büttner
- Institute of Legal Medicine, Rostock University Medical Center, Rostock, Germany
| | - A Öner
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - E Safak
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Berlin, Germany
| | - H Ince
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - J Ortak
- Department of Cardiology, Vivantes Klinikum im Friedrichshain und Am Urban, Berlin, Germany
| | - E Caglayan
- Department of Cardiology, University Hospital, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
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Abstract
NPs care for patients with chronic diseases such as heart failure, chronic obstructive pulmonary disease, cancer, and dementia. As the disease progresses or patients age, disease-related symptoms may become increasingly burdensome, and these patients may benefit from hospice or palliative care. NPs can guide individuals in this process to optimize care and support at the end of life.
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Affiliation(s)
- Kathleen Broglio
- Kathleen Broglio is an NP in the section of palliative care at Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Anne Walsh is an NP at Visiting Nurse Service of New York Hospice and Palliative Care, New York, N.Y
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Pak E, Wald J, Kirkpatrick JN. Multimorbidity and End of Life Care in Patients with Cardiovascular Disease. Clin Geriatr Med 2016; 32:385-97. [DOI: 10.1016/j.cger.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Heart failure (HF) is increasingly common in the United States and is associated with a high degree of morbidity and mortality. As patients approach the end of life there is a significant increase in health care resource use. Patients with end-stage HF have a unique set of needs at the end of life, including symptoms such as dyspnea, uremia, and depression, as well as potentially deactivating implantable defibrillators and mechanical circulatory support devices. Improved palliative care services for patients with HF may improve quality of life and decrease health care resource use near the end of life.
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Affiliation(s)
- Jonathan Buggey
- Department of Medicine, Duke University Medical Center, Duke Medical Hospital, Medical Residency Office/Room 8254DN, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27710, USA
| | - Anthony N Galanos
- Division of Palliative Care, Department of Medicine, Duke University Medical Center, PO Box 3003, DUMC, Durham, NC 27710, USA
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Pfeiffer D, Hagendorff A, Kühne C, Reinhardt S, Klein N. [Implantable cardioverter-defibrillator at the end of life]. Herzschrittmacherther Elektrophysiol 2015; 26:134-140. [PMID: 26001358 DOI: 10.1007/s00399-015-0366-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/24/2015] [Indexed: 06/04/2023]
Abstract
Brady- and tachyarrhythmias at the end of life are common observations. Implantable cardioverter-defibrillators answer with antibrady and antitachycardia pacing, which will not be associated with any complaints of the dying patient. In contrast, defibrillation and cardioversion shocks are extremely painful. Therefore shocks should be inactivated at the end of life. Family doctors, internists, emergency physicians and paramedics are unable to inactivate shocks. Deactivation of shocks at the end of life is not comparable to euthanasia or assisted suicide, but allow the patient to die at the end of an uncurable endstage disease. Deactivation of shocks should be discussed with the patient before initial implantation of the devices. The precise moment of the inactivation at the end of life should be discussed with patients and relatives. There is no common recommendation for the time schedule of this decision; therefore it should be based on the individual situation of the patient. Emergency health care physicians need magnets and sufficient information to inactivate defibrillators. The wishes of the patient have priority in the decision process and should be written in the patient's advance directive, which must be available in the final situation. However the physician must not necessarily follow every wish of the patient. As long as the laws in the European Union are not uniform, German recommendations are needed.
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Affiliation(s)
- D Pfeiffer
- Abt. Kardiologie & Angiologie, Dept. Innere Medizin, Neurologie und Dermatologie, Universität Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland,
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