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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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