Department: CLINICAL QUERIES
Barlow, Christine M. RN
Christine M. Barlow is an RN at Rochester General Hospital in Rochester, N.Y.
The author has disclosed that she has no financial relationships related to this article.
Recently, an older adult with metastatic bladder cancer was admitted to our unit with do-not-resuscitate (DNR)/do-not-intubate (DNI) orders. She also has an implantable cardioverter defibrillator (ICD) because of a history of sustained ventricular tachycardia. Should the ICD be deactivated?—A.H., MINN.
Christine M. Barlow, RN, replies: A DNR order, which must be written by a healthcare provider, documents the patient's wish to avoid CPR in the event that he or she is unresponsive and apneic, with or without pulses. The order addresses resuscitation interventions, which may include rescue breathing, chest compressions, defibrillation, and advanced cardiovascular life support interventions. DNI directs caregivers not to intubate the patient and initiate mechanical ventilation in the event of acute respiratory distress or apnea.
A DNR/DNI order may be chosen by patients who are near the end of life or who have a serious condition that won't improve. It limits only the provider's actions to resuscitate a patient who's pulseless or not breathing; it doesn't restrict other clinically indicated care.1 A patient can revoke a DNR at any time.
Whether an ICD should be deactivated for patients who have a DNR/DNI status depends on each patient's clinical status and wishes. As the health status of a patient with a terminal illness changes, he or she may or may not wish to have the ICD deactivated. In the case of your patient, deactivation of cardiovascular implantable electronic devices, including an ICD, should have been part of the discussion about DNR status. ICD deactivation may have different connotations to the patient and her family than DNR status because they may see it as removing care rather than refusing further treatment.2
As a patient nears the end of life, however, the ICD's response to a dysrhythmia may become burdensome and futile. Kirk cites a case study in which a patient with terminal leukemia in palliative care had an ICD due to preexisting heart disease. Though the caregivers were aware of the ICD, no one discussed deactivation with the patient and the device discharged six times before the patient died.2 Ongoing communication between patients and their healthcare provider helps protect them from unwanted treatments as they near the end of life.
For more information, see the HRS Expert Consensus Statement referenced below.3
2. Kirk TW. Deactivation of automatic implantable cardioverter-defibrillators in hospice and home care patients at the end of life. Home Healthc Nurse. 2008; 26:(7):431–437.
3. Lampert R, Hayes DL, Annas GJ, et al. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm. 2010; 7:(7):1008–1026.