Deactivating the shocking component of an Implantable Cardioverter Defibrillator (ICD) (When no longer appropriate)

The number of implanted ICDs is steadily rising. However, many patients also have significant co-morbidities, and sometimes patients, their relatives and clinicians face issues related to ICD functioning at the end of life, including shocks during the process of dying.

Hospice comments: Leaving the defibrillation function on could potentially cause the patient to experience pain if the device delivers shocks near end of life Leaving the defibrillation device as active does not guarantee, that in the event of an arrhythmia that the heart will be returned to a normal pattern of beating. Turning off the ICD function will not cause death. Turning off the device will not be painful, nor will the patient’s death be more painful if it is turned off.

How to access the Guideline Intranet Controlled Documents, 2764 Deactivation of ICD when no longer appropriate.

Guideline for Deactivation of an Implantable Cardioverter Defibrillator (ICD) Patients with an ICD may receive potentially life-saving therapy in the form of an electrical shock from the device. These shocks are painful and life-saving therapy may be inappropriate for patients with end stage heart failure or other terminal illness..

It may therefore be appropriate in some circumstances for the shock capability of the device to be disabled ICDs are also pacemakers and the pacing function may be altered; if the patient is “pacemaker-dependant” it is very rare for the pacing function to be disabled.

If you wish to disable shocks from an ICD, the following steps should be followed. Discuss with the patient and family, and patients cardiologist in the first instance. If that cardiologist is unavailable, the cardiologist(or designate) on call.

Authorisation must be documented in the clinical notes from a Medical Practitioner Contact the Cardiac Physiologist through 07 8398899 ext 8689 or the operator to arrange a time and venue to meet with the patient, in either the ward or the cardiology department

The Physiologist must sight the written order in the clinical notes prior to any action being taken. The Physiologist should document the programmed changes in the clinical notes.

Please ensure the patient and their family are informed of the process prior to the Physiologist disabling the device and explain death is not likely to occur at the time of deactivation. The patients GP should be informed.

In general, this will be non acute management and should be organised during working hours Monday to Friday. For any concerns please discuss with the patients cardiologist first.

In an emergency situation, if an ICD fires inappropriately most units can be disabled by applying a strong magnet over the unit. Normal function will resume if the magnet is removed; therefore, securing the magnet in place is sometimes necessary.

Magnets are held in: 1. Waikato Hospital- Main Emergency Department, Cardiac Care, ward 14,Pacemaker Clinic, Cardiac theatre 2. Rural hospitals Contact Nurse Coordinator or Duty Nurse Manager. -Thames Hospital held in the Emergency Department -Te Kuiti Hospital in the Emergency Department -Taumaranui Hospital in the Emergency Department -Tokoroa Hospital in the Emergency Department

Points to discuss Clear identification on IPM -patient medical alerts/in patient letters to primary care Acknowledgement and support for the Physiologist carrying out the deactivation procedure