American Clinicians Academy on Medical Aid in Dying

The following is a discussion of this topic on the Listserve of the American Clinicians Academy on Medical Aid in Dying 

Pacemakers and Aid in Dying: To disconnect or leave alone? 

From: Moderator, EOLUpdates. Lonny Shavelson, MD

Sep 10, 2020

to Listserve of the American Clinicians Academy on Medical Aid in Dying 

All,  

One of the most common questions that come into the Academy is about how to deal with pacemakers on or before aid-in-dying days. There’s no formally accepted answer to this, but the question is so common that I’m posting my own approach, and it would be interesting to hear the thoughts of others.  

First: There’s a big difference between a pacemaker and a combined pacemaker/defibrillator (ICD). 

Pacemakers alone: In general, you can (and should) leave these in place and functioning. The last thing you want to have happen is to turn off the pacemaker and have the patient become bradycardic and dizzy or weak before or on the day they plan to take aid-in-dying medications. This is especially true if it’s a continuous pacemaker rather than just in “demand” function.  

But the question often comes up about whether the pacemaker will prolong the time-to-death after the medications are taken. Theoretically, that’s possible, if the patient is dying from an aid-in-dying medication induced bradycardia without other toxic effects. But that pure a mechanism is quite rare. Most commonly, these patients have severely damaged myocardia from hypoxia and digitalis/amitriptyline toxicity–which prevents the pacemaker spike from capturing the myocardium and creating effective beats. What I most commonly see at the time of death of our monitored patients (i.e. all of the patients in my practice, for learning purposes) are pacer spikes without associated capture.   

So for pacemakers alone: Do not disconnect or turn them off.  And there’s no need to worry about significantly prolonging the time to death.  

For pacemaker/defibrillator (ICD) combinations: Since the digitalis/amitriptyline combination can cause tachyarrhythmias (and they often do), there’s a significant chance that the ICD will go off and the patient’s unconscious body will jump slightly from the discharge. This is esthetically unpleasing, but will not significantly delay the death. So I offer these patients and their families a choice: If the family won’t be upset by seeing that slight jump (especially if there’s a clinician there to reassure them), then it’s safe to leave the ICD on.  But if there’s any question about upsetting the patient with the thought of the defibrillator’s discharge, and/or if the family will be upset, it’s not very difficult to call the company and have a technician sent out a few days before the death to turn off the ICD function (but not the pacemaker component).  

In summary: For both pacemakers alone and pacemaker/ICD combinations, it’s fine to do nothing and proceed with aid in dying as you otherwise wuld.  But if you can turn off the ICD, that’s often a good choice.  

Thanks, all.  I look forward to hearing from others about their own practices with pacemaker and/or ICD patients.  

Lonny  

Lonny Shavelson, MD  

Chair Pro-Tem 
American Clinicians Academy on Medical Aid in Dying  

spybarnard 

<[email protected]

Sep 11, 2020 

to Listserve of the American Clinicians Academy on Medical Aid in Dying 

this is an interesting question. 

re ICDs. my practice has always been to deactivate these as soon as someone becomes a DNR, has a comfort directed plan of care, or goes on hospice…. really at any time they are prioritizing quality of life over quantity. it seems a good measure to do whatever the plan is as we know that plans change. In the “good old days” we could all the ICD company rep directly to order it to be turned off at home  or in AL, SNF facility. . in recent times, cardiologists seem to have tighter control and we have to go thru them. still, generally not a problem . its interesting to read you describe “a little jump” as people die. is it really that gentle? one could use an external magnet as well. I’ve been traumatized by witnessing  firing as a person  died before we could grab a magnet. maybe that was atypical? 

The PACEMAKER question is BIG one for me. I’ve worked with several people now who had pacemakers put in for one purpose (when quality of life was good , interested in life prolongation) . as time passes, and quality declines, I have some (not all but a good number) patients want the pacemaker off as they really do not want any thing prolonging life. I totally understand its not an issue with MAID as it will not interfere. But for those who might loose capacity, or are still open to other ways of dying, it can be an important thing. I am distressed by more and more cardiologists seeing a pacemaker as “permenant” and refusing to turn them off when a patient or a designated and legal health care agent asks for this. I have had to advocate strongly about the ethical framework for this (understanding that an individual person can decline, but the system should have a clear way to bypass this objection).  I am curious what is happening in other areas. 

Diana 

Vermont 
 

Timothy Quill 

<[email protected]

Sep 11, 2020

to Moderator, EOLUpdates, Listserve of the American Clinicians Academy on Medical Aid in Dying 

My approach would clearly be to have the ICD function turned off in advance of the procedure.  It is technically noninvasive to deactivate and will potentially prevent multiple shocks toward the very end of the process and may allow for a “sudden death” before MAID is conducted.  I would suggest not deactivating the pacer function in advance (or if it is just a pacer, leave it alone), as this can lead to falls (if the patient is still walking) or fluctuations in consciousness (if intermittently bradycardic) or have no effect if it is not being activated very often.  In non MAID states like NY, where a patient is looking at all options potentially including vsed, testing to see what the pacer is doing may be worth considering as if they are totally dependent on the pacer it might provide another option for them. 

Tim 

mdschaulis 

<[email protected]

Sep 11, 2020 

to Listserve of the American Clinicians Academy on Medical Aid in Dying 

I would consider AICD shock at EOL to be very undesirable. It’s been described as a horse kick to chest to me and certainly looks unpleasant when I’ve seen it, much more than a twitch.  

It’s easy to deactivate them with a magnet – perhaps that should be part of our toolkit.  

Here’s a video that shows how you can do it in one minute. https://youtu.be/1E4oet5-toA 

That seems much better than watching it happen repeatedly.  

Thanks for this topic, 

Monique Schaulis MD 

Here is a short piece about family witnessing ICD shock: https://www.nursingcenter.com/journalarticle?Article_ID=4676802&Journal_ID=54016&Issue_ID=4676797 

–  
  
 

to Listserve of the American Clinicians Academy on Medical Aid in Dying 

On September 12, 2020 Gary Johanson < g.joh…@att.net> wrote: 

Hi Lonny, 

Thanks for drawing attention to the AICD dilemma at EOL. 

We take this issue quite seriously at Providence St Joseph Hospices. 

My experience and the literature notes at times significant distress on the part of observers at time of death; depends on the AICD settings and perhaps other elements of body habits. 

IN any event this phenomenon led to the American Academy of Hospice and Palliative Medicine to actually choose deactivation of AICD’s as one of the 5 most important tents of the care they deliver in the Choosing Wisely “5 Things” initiative of the ABIM. 

Currently in times of COVID, Medtronic and other companies are reluctant to go into the homes to deactivate so we have a number of magnets enabling us to deploy these as needed into the home setting. 

Once out of COVID, technicians are willing to go out to deactivate AICD’s without an MD present, unlike the rare circumstance where patient is requesting deactivation of the pacer (I have been involved in 3 of these in the last few years—they are all very unique stories) in which case the MD needs to be in the home to push the deactivate button. 

Let me know if any further dialogue on this might be useful. 

Gary Johanson, MD 

PALLIATIVE CARE SERVICES 

MEDICAL DIRECTOR, MEMORIAL HOSPICE & HOME HEALTH 

Providence St. Joseph Health 

St. Joseph Health Medical Group                       

439 College Ave. 

Santa Rosa, CA 95401 

T: (707) 568-1094  C: (707) 396-4763 

F: (707) 568-0265      

E: gary.j…@stjoe.org 

www.stjosephhealthmedicalgroup.com 

Reply from Lonny: The obvious difference, of course, between general hospice patients and aid-in-dying patients, is that the aid-in-dying patients are guaranteed to be unconscious by the time they have a medication-induced arrhythmia that might trigger the ICD.  The patients, therefore, have nothing to fear about it going off; the family, though, has to witness the “kick.”  

 
gary.johanson 

<[email protected]

unread, 

9:51 AM   

to [email protected] 

For those running into pushback from cardiology on AICD deactivation in EOL scenarios, 

this consensus panel involving ACC, AGS, AAHPM and others is an ideal document to assist in advocating for deactivation when appropriate 

Gary 

Gary Johanson, MD 

PALLIATIVE CARE SERVICES 

MEDICAL DIRECTOR, MEMORIAL HOSPICE & HOME HEALTH 

Providence St. Joseph Health 

St. Joseph Health Medical Group                       

439 College Ave. 

Santa Rosa, CA 95401 

T: (707) 568-1094  C: (707) 396-4763 

F: (707) 568-0265      

E: gary.j…@stjoe.org 

www.stjosephhealthmedicalgroup.com 

to Listserve of the American Clinicians Academy on Medical Aid in Dying 

From: Lonny Shavelson, MD  9/14/20 

Thank you all (a prestigious group of respondents) for adding to the discussion about pacemaker/ICDs in medical aid in dying.  

I believe there’s a consensus here, so if I may summarize for those on the Listserve:  

Pacemakers can and should be left on before medical aid in dying.  

ICDs, whenever possible, should be turned off — either by the company or by a circular magnet that can be used by any clinician.  

If it is impossible to turn off the ICD, it will not impede the efficacy of aid-in-dying medications nor the patient’s experience of death. But the family may be disturbed by the firing of the ICD.  

Thank you!!  

Lonny