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A Heart Quandary

By Paula Span, The New York Times

June 7, 2012



What does it feel like when the defibrillator implanted in your chest detects a sudden change in heartbeat, an arrhythmia, and delivers a high-voltage shock to return the heart to a normal pace?

“It’s like being punched in the chest, kicked by a horse, hit by a baseball bat – those are the metaphors people commonly use,” said Dr. Daniel Kramer, a fellow in cardiac electrophysiology at Beth Israel Deaconess Medical Center in Boston. “There’s nothing gentle about it.”

Most of the estimated 100,000 people a year who receive this electronic device, about 40 percent of them over age 70, find it a worthwhile trade-off: Getting shocked will hurt and can sometimes cause lingering psychological symptoms, but implantable cardioverter-defibrillators, or ICDs, have also been demonstrated in clinical trials to improve survival in those with certain heart conditions.

As more elderly people acquire these devices, however, they face questions about whether the original implant decision should lead to lifelong use. ICDs have generators that drain in five years on average. Should patients automatically undergo another operation to replace them? It’s also possible to reprogram and thus deactivate an ICD without any intrusive procedure. Does there come a time when people no longer want to be subjected to shocks, even those that may prolong their lives?

A quick definition: ICDs differ from pacemakers, though both are implanted in patients’ chests to regulate arrhythmias. Pacemakers, used to raise too-slow heart rates, emit a low-energy pulse that wearers typically can’t feel. An ICD can also raise a slow heart rate, but is programmable to jolt a fast ventricular arrhythmia back to normal — and there’s no ignoring the zap when it does.


“We can’t predict when the next arrhythmia will happen. It could be when I walk out of the room, or it might never happen,” Dr. Kramer said. Sometimes, too, devices fire “inappropriately” — they malfunction or are fooled by arrhythmias that aren’t dangerous.

So five years later, will people opt for another incision in their chests to replace those drained batteries? Replacements account for at least a quarter of ICD procedures, yet “there’s much less discussion about appropriateness,” Dr. Kramer said. Medicare and professional groups set strict eligibility criteria for which patients should receive devices in the first place, but “there are no meaningful guidelines for whose defibrillators should be replaced,” because there’s little evidence as to who would benefit.

Yet patients can decline replacement, and Dr. Kramer is among those pointing out that in some situations, they might choose to. “The biggest reason is that for a lot of these patients, other illnesses will have emerged,” he said. National registries show that about 12 percent of those receiving defibrillators are over age 80. After five years, “they may have cancers, they may be on dialysis — a lot of other illnesses can progress.” ICDs don’t prevent any other disease, of course, and they could make treatment or life in general uncomfortable.

Replacement, usually an hourlong outpatient procedure that carries a 5 percent chance of complications, could also become more onerous as the years pass. “Older patients are more likely to have prolonged reactions to the sedation,” Dr. Kramer pointed out. So they’re given less of it, which can cause greater pain.

Then there’s the seldom-discussed fact that some people who develop terminal illnesses don’t welcome prolonged lives. Yet a 2010 survey of more than 400 hospices — whose mission, remember, is end-of-life comfort — found that most reported a dying patient being shocked by an ICD within the past year, often multiple times.

Which leads to the related question: Whether or not someone chooses to replace a defibrillator, will he one day simply want it turned off? Physicians are far more likely to have participated in withdrawing other life-sustaining treatments, like ventilators or feeding tubes, than ICDs or pacemakers, one of Dr. Kramer’s studies found. They’re less comfortable even discussing the prospect of turning these devices off.

Yet patients don’t seem nearly as uneasy. In 2010, Katy Butler wrote movingly in The New York Times Magazine of her family’s efforts to get her ailing father’s pacemaker disconnected.

John Dodson, a Yale cardiology and geriatrics fellow, has studied 95 ICD users (average age: 71) presented with five hypothetical situations: Would you want the device deactivated if you were unable to get out of bed? If memory problems left you unable to recognize your family? If you were on a ventilator or had an advanced, incurable disease? In his preliminary results, more than 70 percent said that in at least one such situation, they would opt for deactivation.

“These conversations are important to have,” said Dr. Dodson. “It’s something I anticipate talking about with my patients.”

There’s scant data on how many ICD recipients ever have that frank talk, but “we suspect we could be doing a much better job,” Dr. Kramer said. In our fragmented medical system, the specialist who implants or replaces is unlikely to know a patient well or may not coordinate with other specialists treating his other ailments. Besides, Dr. Kramer points out, “in a fee-for-service world, you’re paid to do procedures, not decline them.”

So things like this happen: Last year, Dr. Kramer saw a woman in her 80s whose ICD had become depleted. “It would not have surprised us if she’d declined to have a replacement,” he told me. “She was pretty savvy and was aware of the options.” After discussion, however, she decided to keep her ICD active, so Dr. Kramer replaced its batteries.

Less than a year later, she developed metastatic cancer and, after several hospitalizations, entered a residential hospice. There, because the staff didn’t initially know she had an ICD and her cardiologist didn’t know she’d chosen comfort care, her still-functioning device shocked her eight times over several days.

Hospice workers, prompted by her frantic family, called Dr. Kramer. He went to the hospice and deactivated the ICD, allowing her, four days later, to die in peace.



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