Imagine that you are attending a loved one’s last few hours, his final phase of active dying. As you watch, his breathing becomes apneic and his limbs begin to cool. He is restful and at peace. Suddenly, his body is seized with a convulsion. You watch in horror as the shocks continue, and you realize that your patient’s Implantable cardioverter defibrillator (ICD) is delivering high-voltage electrical shocks into his heart. The machine doesn’t know that it is causing pain and suffering. It’s just a machine, and it’s doing what we told it to. We are the ones that have failed.
This is a real problem. In their article “Management of Implantable Defibrillators in Hospice”, Dr. Goldstein et al report that more than three quarters of hospices admitted patients with active ICDs in the last year, and that :
58% of hospices reported that at least one person was shocked in the last year, and 40% of those reported that at least one patient had received multiple shocks during a single episode.
Sometimes physicians make mistakes that are unacceptable, like consistently ignoring a patient’s pain. In other cases, the errors are omissions, like forgetting the patient has an ICD, and thus not remembering to turn it off.* It’s an understandable error, but that will be of little consolation to the patient and family that suffer through a terrible death.
If you know your palliative care patient has an ICD, or you feel a device in the chest and confirm its presence, ask the patient/family if the device is still active. If it is, explain that it could cause needless suffering by giving electrical shocks that may no longer be desired. With their permission, call the cardiologist to help arrange for the device company (Medtronic and Guidant are two common ones) to send a technician that can deactivate the defibrillator. In an emergency, apply a powerful magnet to the skin over the device to prevent it from firing.
*(Note that there’s no need to turn off a pacemaker; its electrical signals are tiny painless pulses that cannot be felt, and it will not prolong life or cause suffering. Unfortunately, one cannot know simply from palpating the device whether it contains a defibrillator, pacemaker, or both.)