Hearts of Hospice Patients Being Needlessly Shocked
THURSDAY March 4, 2010 -- Hospices that care for people who are dying often forget to turn off their implanted defibrillators, causing unnecessary discomfort, new research has found.
Only 20 percent of more than 400 hospices that responded to a survey indicated that they had a question on their admitting form that would identify people with defibrillators, and just 10 percent said it was their policy to discuss deactivating the devices, according to a report by physicians at the Mount Sinai School of Medicine in New York City, published March 2 in the Annals of Internal Medicine. The survey found that 97 percent of the hospices, though, had admitted people with implanted defibrillators.
A defibrillator delivers a shock to restore a normal heartbeat in people with rhythm abnormalities. "The purpose is to save a patient's life," said study author Dr. Nathan Goldstein, an assistant professor of geriatrics and palliative medicine at Mount Sinai. "There is a little burden, but mostly benefit. But there is no sense getting a shock when it is not going to fix their underlying condition."
Some hospice patients have compared the shock given by a defibrillator to being kicked or punched in the chest, Goldstein said.
He cited the case of a man who was dying of cancer and was shocked repeatedly by an implanted defibrillator. "That is very painful for the patient and upsetting for the patient and the family," Goldstein said.
A policy statement issued by the National Hospice and Palliative Care Organization said that all people with implanted defibrillators should be identified on admission to a hospice and that the option of deactivation "should be thoroughly explored with patients and their designated caregivers as soon as possible after admission."
The discussion should include an explanation that deactivation "does not constitute euthanasia nor physician-assisted suicide nor is it likely to hasten death," the statement said. If the device also acts as a pacemaker, that function can be maintained, it said.
"We put out this statement in 2008 because we knew that it was becoming an increasingly important issue in dealing with patients at the end of life," said Jon Radulovic, vice president for communications at the National Hospice and Palliative Care Organization. "We recognize that many hospices have a way to go to put a policy in place. The research out of Mount Sinai reminds us of how important this issue is. We now know that a lot of work needs to be done out there in the provider community in meeting the recommendation."
A conversation about turning off a defibrillator because the end of life is near is not easy to begin, Goldstein said, and many hospices "do not have a systematic way of having a conversation about the possibility of turning off defibrillators."
Family members who observe hospice patients being shocked report feelings of fear, worry and helplessness and have been shown to have increased rates of anxiety and depression, he said.
Goldstein's team has developed a model policy for managing implanted defibrillators in hospice settings. It includes an informed-consent discussion with the family and information on handling the device in an emergency.
"What is remarkable about Dr. Goldsteins study is what it uncovered," said Dr. Paul S. Mueller, director of the program in professionalism at the Mayo Clinic, who has done research on defibrillators in the end-of-life setting. "Here you have patients who have been admitted to the hospice program because they have terminal illnesses or will not live six months."
"The defibrillator is a life-preserving device. Is that kind of treatment consistent with a hospice program oriented toward end-of-life care? It would seem to be inconsistent with the goal of hospices," he added.
But one relatively bright point is that hospices that ask about defibrillators on admission are more likely to take steps to deactivate the devices, Mueller said.
Learn about defibrillators from the American Heart Association.
Posted: March 2010
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