Doctoring Hospice/Palliative Care ICD/Pacemaker

ICD deactivation in the NY Times — with a quote from a blogger

The news came via a direct message on Twitter. “You got a plug in the NY times. Congrats.” (Thanks Dr. Jay Schloss.)

Paula Span, author of the NY Times’ The New Old Age Blog, reported today on the issue of cardiac device deactivation in patients who are approaching end of life.

The role I had in the piece stems from the editorial I co-authored with University of Colorado Professor Dr. Dan Matlock in the Journal of the American Medical Association-Internal Medicine. 

I think this is my first mention in the Times. It’s especially nifty because end-of-life care is such an important topic.

Yes, cardiac devices can do a lot of good for people. They improve lives. They extend lives. I’m not sure why my brain works this way, but when I see an ICD printout showing a sudden death episode averted by something I did, I often think that I once was a paper boy. How’s it possible that a goofball like me could save a life? The hashtag here would be…#beautiful. Or…#I’d-still-go-to-med-school-again.

But cardiac devices are no small deal. They come with risks. Serious risks, like this one: essentially every patient with a cardiac device ends up dying with it still implanted. Death is certain, so the once useful device eventually sheds its usefulness. ICDs are implanted to prevent sudden death, but most ICD patients (approximately 14/15) don’t die suddenly; they die of something else, something less peaceful. These truths call doctors to help patients formulate a plan before the inevitable occurs. The ICD discussion presents an ideal chance to speak with patients about their goals for care. Yet, as the Mayo Clinic researchers showed in the study that Dan and I commented on, it rarely happens–even at places like the Mayo Clinic.

This is not surprising. Nothingness is no easy topic. Death is vast. When I had a concussion, and was out of it for 30 minutes, it was as if I was nothing for those minutes. One minute I was here, and the next gone. The weird part is that if I hadn’t come back, I wouldn’t have known I existed. This is heavy stuff. You can see why it gets pushed aside.

Patients get seen. Ejection fractions measured. Devices implanted. Paperwork completed. All are happy. No one dies. No one talks about dying.

Taking this path, however, the one where action obscures the reality of death, has never been more risky. ICUs and nursing homes overflow with patients stripped of their dignity, mostly because these poor souls had no plan to avoid death-prolonging care.

The ICD provides a great opportunity for a caring physician to make a difference.

Ms. Span explains:

Dr. Matlock argues that any doctor who knows how to implant a cardiac device — any doctor, period — can also learn to have a conversation about what a patient wants to do about it as the years pass, and to renew that dialogue (it should also include the matter of replacing I.C.D.’s when their batteries die, which requires additional surgery) at follow-up visits…

…But the current reality, Dr. Matlock says, is that “a lot of doctors would have trouble with this conversation. It’s much easier to say, ‘Your device looks fine. See you in a year.’”

My friend is right. Specialists, like electrophysiologists, cardiologists, oncologists, surgeons, are the caregivers best positioned to align therapy with a patient’s goals. We understand what our treatments can and cannot do. We know the downsides. We (should) know the patient.

Here it seems right to quote one of the most famous cardiologists of our era. During a debate at a national gathering of cardiologists, distinguished professor Dr. Mark Josephson, said that he hated the term proceduralist. “You are not proceduralists, you are doctors.”


Here’s a link to my original post on DrJohnM

Shelley Wood, managing Editor for|Medscape Cardiology, covered the story as well.

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