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Difficulty: HardEnd-of-Life and Palliative Care

A 71-year-old male with a history of ischemic cardiomyopathy is evaluated in the hospital. Three years ago, he received a left ventricular assist device (LVAD) as destination therapy, along with an implantable cardioverter-defibrillator (ICD). He was recently admitted with progressive jaundice, weight loss, and severe abdominal pain, and has just been diagnosed with widely metastatic pancreatic adenocarcinoma. Oncology evaluation concludes he is not a candidate for disease-directed therapy due to his poor performance status and advanced disease stage.

The patient is fully alert, conversant, and demonstrates intact decision-making capacity. He expresses a clear desire to focus exclusively on comfort, wishes to avoid any further life-prolonging or painful interventions, and wants to return home with hospice services. He emphasizes a strong fear of experiencing severe shortness of breath or painful shocks during his final days. His current hemodynamics are stable on his baseline LVAD settings, and he is not experiencing dyspnea at rest.

Which of the following is the most appropriate next step in the management of his cardiac devices?

  1. Deactivate the defibrillator function of the implantable cardioverter-defibrillator while continuing left ventricular assist device support.Answer
  2. B
    Deactivate both the left ventricular assist device and all functions of the implantable cardioverter-defibrillator prior to discharge.
  3. C
    Require a formal psychiatric evaluation to establish legal competence before allowing the deactivation of the implantable cardioverter-defibrillator.
  4. D
    Inform the patient that he must be discharged to an inpatient facility because home hospice agencies cannot accept patients with active left ventricular assist devices.
  5. E
    Initiate high-dose methadone for abdominal pain and maintain the active implantable cardioverter-defibrillator to protect against methadone-induced torsades de pointes.

Answer

Deactivate the defibrillator function of the implantable cardioverter-defibrillator while continuing left ventricular assist device support.
The correct approach balances the patient's desire for comfort and his fear of dyspnea. Deactivating the ICD's defibrillator function eliminates the risk of painful shocks during the dying process, aligning with comfort goals. Conversely, maintaining the LVAD is crucial because it actively prevents the acute pulmonary edema and severe shortness of breath that would rapidly ensue if the device were turned off. This strategy provides optimal palliative symptom control while honoring the patient's wish for a peaceful death at home.

Step-by-Step Solution

1
Identify the patient's primary goals of care.
The patient wants purely comfort-focused care at home, specifically avoiding painful interventions and severe shortness of breath.
All medical management decisions at the end of life must be guided by the patient's articulated values and goals.
2
Evaluate the role of the implantable cardioverter-defibrillator (ICD) in the context of these goals.
The defibrillator function of the ICD delivers painful shocks to prevent sudden cardiac death. This conflicts with the goal of comfort and a natural death.
Painful life-prolonging interventions are contraindicated when the goal is strict comfort.
3
Evaluate the role of the left ventricular assist device (LVAD) in the context of these goals.
The LVAD maintains forward blood flow and prevents backward failure. Deactivating it would likely cause acute pulmonary edema and severe dyspnea, which the patient explicitly fears.
Interventions that provide significant symptom relief (palliative benefit) should be maintained even in hospice care.

Key Concept

Management of cardiac devices at the end of life requires differentiating between interventions that cause pain and prolong the dying process (like ICD shocks, which should be deactivated) and those that provide palliative symptom relief (like LVADs preventing dyspnea, which can be maintained).
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Topics

End-of-Life and Palliative Care

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