Years ago – when I first started working in hospice – dealing with implantable cardioverter defibrillators and pacemakers in hospice patients was essentially unheard of. As with everything in life, things change. More and more patients are being admitted to hospice with implantable cardioverter defibrillators and pacemakers. This can be an issue if not addressed. The purpose of hospice is to allow nature to take its course, ensure that the patient is comfortable and ensure that the family is supported. Understanding how these devices work is paramount to meeting those goals.
What is an implantable cardioverter defibrillator?
An implantable cardioverter defibrillator (ICD) is a battery operated device, inserted under a person’s skin, generally right beneath the collarbone with very thin wires leading to the heart. The battery pack monitors the heart’s function. When a recurrent or dramatic abnormal heart beat (known as an arrhythmia) occurs, the device will send a signal or impulse through the wires to the heart. This signal essentially “shocks” the heart in an attempt to convert it back into an acceptable rhythm. This can occur when the heart is beating too quickly, too slowly or too erratically.
When the device activates and triggers an impulse, patients often state that it can be incredibly painful. Some state that feels like someone thumping their chest or a sudden jolt. Some patients even pass out during the event so they may not feel the shock at all.
The purpose of this device is to reduce a person’s chances of having a cardiac event that results in a cardiac arrest. The ICD does not treat the underlying condition causing the abnormal heart beats or “cure” a person’s heart disease. It is strictly intervening to treat the abnormal arrhythmias. If an individual has a terminal heart condition, the ICD will not reverse that condition.
Although the ICD can be a good device, once a person is terminally ill, this device can become an issue – especially if the person with the device is receiving multiple shocks. We want to keep the patient comfortable. Having an ICD sending signals to shock the heart of a patient isn’t typically comfortable for them. It can also be disturbing for the hospice professional that only wants to make sure that the patient is comfortable.
There are solutions to this problem. One option is to “deactivate” the ICD. This essentially means turning off the device so it no longer sends the impulse. This may sound scary, but families should be aware that most people are not going to immediately die from turning off the device. The device isn’t a substitute for the heart; it is only a tool to keep the heart beating as efficiently as possible. Even after turning off or deactivating the ICD, the heart will typically continue to function, but now will be susceptible to the irregular heart rhythm that warranted the device to be inserted in the first place.
Another option – after obtaining a physician’s order – is using a large magnet to interfere with the function of the ICD. The nurse essentially holds a magnet over the device to try to prevent it from sending shocks to the heart by interrupting the signals.
One thing to remember is that deactivating an ICD device isn’t a sign of giving up. In fact, it is a way of being very proactive in one’s own healthcare and making sure that they are taking the necessary actions to remain as comfortable as possible in the time left.
What is a pacemaker?
There can be lots of confusion between the pacemakers and ICDs. Although both are inserted into the body, pacemakers are a completely different animal. Pacemakers are essentially a tool that keeps the heart from beating too slowly.
The pacemaker doesn’t send “shocks” to the heart like the ICD does. It works by sending energy to stimulate the actual heart muscle to keep the heart from beating too slowly. It does not replace the function of the heart, but does assist the heart in beating regularly and more quickly.
The other difference is that the pacemaker can actually cause more discomfort for the patient if deactivated. Therefore, it is usually not recommended to discontinue or to take the more invasive step of actually removing the pacemaker. The heart will stop when death occurs. The pacemaker does not prolong life, nor does it cause the heart to continue to beat indefinitely.
Once the person stops breathing, there is no longer oxygen being sent through the body. At this point, the heart muscle which is no longer getting the oxygen it needs, will eventually die and the beating of the heart will stop. This is not painful, nor is it prolonging the patient’s life.
The key to maximizing the benefit of both the ICD and the pacemaker is good, honest, and direct communication with your healthcare provider. Understanding how these devices function and when to disable the ICD for maximum patient comfort, sets the stage for a beneficial and successful hospice experience.
The team at Crossroads Hospice & Palliative Care is here to help you understand these devices and how they relate to hospice and palliative care. For more information, contact us at 1-888-564-3405.
DeAnna Looper RN, CHPN, CHPCA, LNC
Senior Vice President of Clinical Operations
Carrefour Associates, L.L.C.
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