Device Deactivation and Allied Health Professionals July 5, 2010
Posted by christinechiuman in Health Policy.Tags: HRS guidelines, Scientific Sessions
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The Heart Rhythm Society’s Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy was released at the society’s 31st Annual Scientific Sessions in Denver.
For decades, CIEDs – pacemakers, implantable cardioverter-defibrillators, and more recently cardiac resynchronization therapy devices – have proven to save lives in various populations at risk of serious heart rhythm disorders. As indications for device therapy continues to expand, the population of patients with these devices continues to grow.
The Society’s new consensus statement is the first to offer clinicians and industry guidance on the management of CIEDs in those patients who are at the end of their lives or requesting withdrawal of device therapy. This post discusses the document’s merits for the allied professional.
Allied health professionals (APs), referred throughout the Consensus Statement as “clinicians,” along with physicians and other cardiac and patient care givers will find that it is not uncommon to encounter patients who are approaching the end of life and request device deactivation and/or withdrawal. This report is of particular relevance and interest to both clinicians and industry employed allied professional personnel as it reviews the fundamental principles of device deactivation from an ethical and legal perspective, while providing communication and management strategies on caring for patients who request device deactivation.
Among the many issues that the Consensus Statement addresses are:
- How should we, as allied professionals, manage and care for these patients?
- How do we respect the values and attitudes of patients from different cultures or religions?
- What is our role in deactivating devices?
- What if we are not comfortable turning a device off?
The five key points from this document that affect our practice are:
1. The document recognizes the vital role that clinical (“clinicians”) or industry employed allied professionals play in patient care, education and device management.
2. Emphasis is placed on proactive discussion with patients to minimize ethical dilemmas. It recommends that we begin discussion with patients about their options and alternative therapies at the time of device implant, such as establishing advanced directives that include addressing the management of the implantable device when the patient is nearing end of life or has terminal illness.
3. We need to recognize that from an ethical and legal perspective, patients do have a personal right to refuse or request withdrawal of treatment.
4. Clinicians and industry-employed APs can choose not to participate in device deactivation without needing to be removed from the patient’s care process, as long as adequate arrangement is made to transfer care to another clinician.
5. It is important that established protocols should be in place at each institution regarding withdrawal of therapies, including device deactivation.
Allied professionals can learn more about the issues involved with device deactivation in patients nearing the end of life by reading the Consensus Statement and sharing their experiences with each other. We also invite you to periodically check in with the Society’s Clinical Documents webpage for future developments regarding the consensus statement.
How do you foresee this guidance helping you in your practice?
Heart Rhythm Society
Laurie Racenet, RN, MSN, ANP
Michael Giudici, MD, FACC, FACP, FHRS
Heather M. Ross, DNP, ANP-BC, CCDS, CEPS, FHRS
Anne Dubin, MD, FHRS
John D. Day, MD, FHRS
Andrea M. Russo, MD, FACC, FHRS
Joshua M. Cooper, MD, FACC
Amit J. Shanker, MD, FHRS, FACC
Bruce Stambler, MD
David Wiggins, RN, BS BME, CEPS
Fred M. Kusumoto, MD, FHRS
Leonard Ganz, MD, FHRS
christinechiuman
Craig Delaughter, MD, PhD
Ariana Del Negro, Heart Rhythm 2010 Quality
Peng-Sheng Chen, MD, FHRS
MSKremers MD,FHRS
Ann C. Garlitski, MD, FACC, FHRS
Alan Cheng, MD, FHRS
Ulrika Birgersdotter-Green, MD
Christopher Clyne, MD, FHRS
Kathleen Blake, MD, MPH, FHRS
David Scher, MD, FHRS
Sanjay Deshpande, MD, FHRS
This consensus statement identifies that a CIED deactivation order must be from a “responsible physician” which may be “the patient’s primary care physician, cardiolo- gist, cardiac electrophysiologist, a hospitalist, or a palliative care specialist.” In the United States, Medicare rules specify that a patient may elect a nurse practitioner to be the attending physician for hospice care, once hospice eligibility has been determined by a physician.
In light of this phenomenon of nurse practitioner as the attending provider, and particularly with the legislated expansion of nurse practitioner roles as primary care and medical home providers, should this ordering restriction be reconsidered in an effort to avoid unnecessary barriers to care at the end of life?
This is a great question, the issue was not specifically addressed in the document, and doesn’t seem to be an easy one to answer. Let’s see if anyone from the writing group can provide more insight into this.