Examkin

Question

Difficulty: HardEnd-of-Life and Palliative Care

A 78-year-old man with end-stage ischemic cardiomyopathy (left ventricular ejection fraction 15%) and NYHA class IV heart failure is admitted to an inpatient hospice facility. He has a biventricular pacemaker with an implantable cardioverter-defibrillator (CRT-D) in place. Upon admission, a 'Do Not Resuscitate' order is confirmed. On his second day in the facility, his condition declines; he becomes obtunded and is determined to be in the actively dying phase. Shortly after, he experiences a sustained episode of ventricular tachycardia and receives a high-voltage shock from his CRT-D, causing his body to jolt and resulting in visible physical distress. His wife, who is his legally designated healthcare proxy, is at his bedside. She is terrified by the event and asks the attending physician to 'turn the machine off' to prevent further shocks. However, she expresses fear that doing so will cause him to immediately suffocate. Which of the following is the most appropriate next step in management?

  1. A
    Consult electrophysiology to urgently deactivate both the defibrillating and the pacing functions of the device.
  2. B
    Transfer the patient to a cardiac step-down unit for telemetry monitoring while awaiting a device technician.
  3. Place a clinical magnet over the device and reassure the wife that this will solely disable the shock function.Answer
  4. D
    Inform the wife that a court order determining the patient's legal competence is required before the device can be deactivated.
  5. E
    Contact the patient's adult children to obtain unanimous family consensus before altering the function of the device.

Answer

Place a clinical magnet over the device and reassure the wife that this will solely disable the shock function.
The most appropriate next step is to place a clinical magnet over the device. In patients with an implantable cardioverter-defibrillator (ICD) who are transitioning to comfort-focused care or are actively dying, the shock function (tachytherapies) should be deactivated to prevent painful and distressing shocks. Applying a clinical magnet over the ICD generator is a rapid, widely available method that temporarily suspends tachycardia detection and therapies. Crucially, the magnet does not deactivate the bradycardia pacing function. In a patient with advanced heart failure and a biventricular pacemaker (CRT-D), maintaining the pacing function is essential for symptom control, as sudden loss of resynchronization can precipitate acute pulmonary edema and severe dyspnea. This action perfectly aligns with the proxy's goals and addresses her fears.

Step-by-Step Solution

1
Identify the patient's clinical status and goals of care.
The patient is actively dying and has a DNR order; the overarching goal is strictly comfort.
Establishing the goal of care is a prerequisite for making appropriate end-of-life interventions.
2
Evaluate the current symptom crisis.
The patient is receiving painful ICD shocks for ventricular tachycardia.
ICD shocks cause severe physical distress and are completely contrary to comfort goals.
3
Determine the appropriate intervention for the CRT-D device.
Disable the defibrillator (shock) function while maintaining the pacemaker (resynchronization) function.
Turning off shocks prevents pain, while maintaining pacing prevents acute worsening of heart failure (e.g., severe dyspnea and pulmonary edema) which would cause further distress.
4
Select the most immediate and practical method to achieve this specific device state.
Place a clinical magnet over the device.
A magnet immediately suspends tachytherapies without requiring an electrophysiology technician or programmer, allowing rapid relief of suffering while keeping pacing active.

Key Concept

Management of Implantable Cardioverter-Defibrillators (ICDs) in Hospice and Palliative Care

Alternative Method

In the absence of a magnet, the physician must urgently contact the device manufacturer's representative or an electrophysiologist to program the device to 'tachytherapy off' via a specialized programmer. However, this delays immediate symptom relief.
Estimated Time:1m 30s
Rate this question

Topics

End-of-Life and Palliative Care

More questions from this topic