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Question

Difficulty: MediumEnd-of-Life and Palliative Care

A 79-year-old man is evaluated during a home hospice visit. He has end-stage ischemic cardiomyopathy and was enrolled in hospice care one week ago. He spends most of the day in bed and experiences severe dyspnea and fatigue with minimal exertion. His medications include a continuous furosemide infusion and low-dose oral morphine for dyspnea. He has a cardiac resynchronization therapy defibrillator (CRT-D) that was implanted four years ago. His wife is his designated healthcare proxy. She expresses concern that the device might shock him when he is dying, which she fears would be painful and distressing. He is currently comfortable, with a heart rate of 78/min and blood pressure of 96/60 mmHg. Which of the following is the most appropriate next step in management regarding the patient's CRT-D?

  1. Deactivate the defibrillator function and maintain the biventricular pacing functionAnswer
  2. B
    Deactivate both the defibrillator function and the biventricular pacing function
  3. C
    Maintain both device functions active and prescribe sublingual lorazepam for post-shock anxiety
  4. D
    Provide a ring magnet with instructions to apply it over the device only if multiple shocks occur
  5. E
    Arrange for outpatient surgical explantation of the device under local anesthesia

Answer

Deactivate the defibrillator function and maintain the biventricular pacing function.
In patients with an implantable cardioverter-defibrillator (ICD) who are entering hospice care, the defibrillator (shock) function should be proactively deactivated. Shocks are intensely painful, cause significant distress to both the patient and family, and do not alter the underlying terminal disease trajectory. However, for devices that also provide cardiac resynchronization therapy (CRT-D) or standard pacing, the pacing function should remain active. Biventricular pacing in end-stage heart failure reduces symptoms such as severe dyspnea and fatigue by maintaining cardiac synchrony. Deactivating the pacing function can precipitate acute hemodynamic decompensation and worsen the patient's comfort, which contradicts the fundamental goals of palliative care.

Step-by-Step Solution

1
Identify the primary goals of care based on the patient's disposition.
The patient is in home hospice, prioritizing symptom management and comfort over life prolongation.
Establishing the care framework is required to guide decisions regarding medical technology.
2
Evaluate the dual functions of a CRT-D device.
The device provides defibrillation (which is life-prolonging but painful) and biventricular pacing (which is symptom-relieving).
Different functions of the same device may have conflicting effects on the goal of comfort.
3
Align device management with the goals of care.
The defibrillator should be deactivated to prevent distress, while pacing should be maintained to prevent acute dyspnea.
This strategy maximizes comfort while minimizing iatrogenic harm during the dying process.

Key Concept

Management of cardiovascular implantable electronic devices (CIEDs) in hospice care
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Topics

End-of-Life and Palliative Care

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