Nathan E. Goldstein

HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy.

1 RS Expert Consensus Statement on the Management of ardiovascular Implantable Electronic Devices (CIEDs) in atients nearing end of life or requesting withdrawal of therapy his document was developed in collaboration and endorsed by the American College of Cardiology ACC), the American Geriatrics Society (AGS), the American Academy of Hospice and Palliative edicine (AAHPM); the American Heart Association (AHA), the European Heart Rhythm ssociation (EHRA), and the Hospice and Palliative Nurses Association (HPNA).

That's like an act of suicide patients' attitudes toward deactivation of implantable defibrillators.

ObjectiveTo understand potential patient barriers to discussions about implantable cardioverter defibrillator (ICD) deactivation in patients with advanced illness.DesignQualitative focus groups.ParticipantsFifteen community-dwelling, ambulatory patients with ICDs assigned to focus groups based on duration of time since implantation and whether they had ever received a shock from their device.ApproachA physician and a social worker used a predetermined discussion guide to moderate the groups, and each session was audiotaped and subsequently transcribed. Transcripts were analyzed using the method of constant comparison.ResultsNo participant had ever discussed deactivation with their physician nor knew that deactivation was an option. Patients expressed a great deal of anxiety about receiving shocks from their device. Participants discussed why they needed the device and expressed desire for more information about the device; however, they would not engage in conversations about deactivating the ICD. One patient described deactivation “like an act of suicide” and all patients believed that the device was exclusively beneficial. Patients also expressed a desire to have their physician make the decision about deactivation.ConclusionsNone of the patients in our study knew that they might need to deactivate their ICD as their health worsens. These community-dwelling outpatients were not willing to discuss the issue of ICD deactivation and their attitudes about deactivation might impede patients from engaging in these conversations. These findings are in contrast to findings in other advance care planning research and may be related to the unique nature of the ICD.

It's Like Crossing a Bridge Complexities Preventing Physicians from Discussing Deactivation of Implantable Defibrillators at the End of Life

OBJECTIVETo understand potential barriers to physician-initiated discussions about Implantable Cardioverter Defibrillator (ICD) deactivation in patients with advanced illness.DESIGNQualitative one-on-one interviews.PARTICIPANTSFour electrophysiologists, 4 cardiologists, and 4 generalists (internists and geriatricians) from 3 states.APPROACHClinicians were interviewed using open-ended questions to elicit their past experiences with discussing deactivating ICDs and to determine what barriers might impede these discussions. Transcripts of these interviews were analyzed using the qualitative method of constant comparison.RESULTSAlthough many physicians believed that conversations about deactivating ICDs should be included in advance care planning discussions, they acknowledged that they rarely did this. Physicians indicated that there was something intrinsic to the nature of these devices that makes it inherently difficult to think of them in the same context as other management decisions at the end of a patient’s life. Other explanations physicians gave as to why they did not engage in conversations included: the small internal nature of these devices and hence absence of a physical reminder to discuss the ICD, the absence of an established relationship with the patient, and their own general concerns relating to withdrawing care.CONCLUSIONWhereas some of the barriers to discussing ICD deactivation are common to all forms of advance care planning, ICDs have unique characteristics that make these conversations more difficult. Future educational interventions will need to be designed to teach physicians how to improve communication with patients about the management of ICDs at the end of life.

Brief Communication: Management of Implantable Cardioverter-Defibrillators in Hospice: A Nationwide Survey

BACKGROUND Communication about the deactivation of implantable cardioverter-defibrillators (ICDs) in patients near the end of life is rare. OBJECTIVE To determine whether hospices are admitting patients with ICDs, whether such patients are receiving shocks, and how hospices manage ICDs. DESIGN Cross-sectional survey. SETTING Randomly selected hospice facilities. PARTICIPANTS 900 hospices, 414 of which responded fully. MEASUREMENTS Frequency of admission of patients with ICDs, frequency with which patients received shocks, existence of ICD deactivation policies, and frequency of deactivation. RESULTS 97% of hospices admitted patients with ICDs, and 58% reported that in the past year, a patient had been shocked. Only 10% of hospices had a policy that addressed deactivation. On average, 42% (95% CI, 37% to 48%) of patients with ICDs had the shocking function deactivated. LIMITATION The study relied on the knowledge of hospice administrators. CONCLUSION Hospices are admitting patients with ICDs, and patients are being shocked at the end of life. Ensuring that hospices have policies in place to address deactivation may improve the care for patients with these devices. The authors provide a sample deactivation policy. PRIMARY FUNDING SOURCE National Institute of Aging and National Institute of Nursing Research.

Prescribing discrepancies likely to cause adverse drug events after patient transfer

Background: Medication-prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing. Methods: We examined medical records of patients transferred between seven nursing homes and three hospitals between 1999 and 2005 in New York and Connecticut for transfer-associated prescribing discrepancies. ADEs caused by discrepancies were determined by two clinician raters. We calculated the fraction of medication discrepancies that caused ADEs in each of 22 drug classes by calculating positive predictive values (PPVs). We calculated the discrimination of a count of high-risk drug discrepancies, selected from published lists of high-risk medications and using observed PPVs. Results: 208 patients were hospitalised 304 times. Overall, 65 of 1350 prescribing discrepancies caused ADEs, for a PPV of 0.048 (95% CI 0.037 to 0.061). PPVs by drug class ranged from 0 to 0.28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Patients with 0, 1–2 and ⩾3 high-risk discrepancies had a 13%, 23% and 47% chance of experiencing a discrepancy-related ADE, respectively. Conclusions: Discrepancies in certain drug classes more often caused ADEs than other types of discrepancies in hospitalised nursing-home patients. Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients and inform the development of decision-support tools at the time of patient transfer.

Barriers to Conversations About Deactivation of Implantable Defibrillators in Seriously Ill Patients : Results of a Nationwide Survey Comparing Cardiology Specialists to Primary Care Physicians

Implantable Cardioverter-Defibrillators (ICDs) reduce sudden cardiac death. However, about 25% of patients with ICDs are shocked in the last month of life(1), and these shocks may cause frightening and painful deaths. Little is known about how physicians’ attitudes influence their decisions to discuss ICD deactivation with patients. We created a simple random sample of the American Medical Association Masterfile by choosing 100 physicians from each of four strata: electrophysiologists, cardiologists, geriatricians, and internists. Eligible clinicians had to be in active practice and had to have cared for at least one patient with an ICD. We mailed letters to all physicians introducing the study, and then followed up by telephone to administer the survey. Physicians who could not be contacted telephonically were mailed surveys, and a series of incentives were used to encourage participation. All surveys were anonymous. This project was exempt from review by the Mount Sinai School of Medicine IRB. We based the survey on our previous qualitative work.(2,3) The instrument included Likert scales (1 (strongly disagree) to 5 (strongly agree)) to determine physicians’ attitudes relating to ICD conversations (Table 1). Data were analyzed as both continuous and dichotomous variables. As the results of these analyses were similar, the Likert scales are reported as strongly agree or agree versus all others. For between group comparisons, the chi-square test was used; Fisher’s Exact test was used for smaller cell sizes. P-values reflect comparisons across the four groups. There was no difference in response patterns between phone and written surveys. ANOVA was used to evaluate the differences in age of respondents across the four groups. Significance levels for individual tests were not adjusted as the survey was based on qualitative data and the sample size was small thus making it unlikely that any observed association would be due to chance alone.(4) All calculations were performed using SAS v9.0 (Cary, NC). Table 1 Results of 5-point Likert scales to Determine Physicians’ Attitudes Relating to Care of Patients with ICDs Of the 400 physicians selected for the survey, 11 were deemed ineligible (7 were retired and 4 had never cared for a patient with an ICD) and 52 could not be located. Of the remaining 337 eligible physicians, 147 completed surveys, yielding a response rate among physicians who could be located of 44% (147/337). Electrophysiologists had a higher response rate (58%) compared with cardiologists (36%), internists (37%) and geriatricians (41%) (p=.013). Geriatricians tended to be older than cardiologists, electrophysiologists, or internists (mean age 54.1 years vs. 48.3, 49.0, and 48.1 respectively, p-value<0.001). The likelihood of being male was higher among electrophysiologists (92%) and cardiologists (93%) than among geriatricians (62%) and internists (66%) (p-value<0.001). Clinicians’ views about care for seriously ill patients with ICDs varied across specialty. Electrophysiologists were less likely than cardiologists, internists, or geriatricians to agree/strongly agree that they could accurately predict the possibility of a patient being shocked by the ICD near the end of life (12% versus 41%, 46%, and 30%, respectively) (p=.005). With respect to patient understanding, 94% of electrophysiologists and 93% of cardiologists who responded strongly agreed/agreed with the statement that their patients understood why they had an ICD, whereas only 74% of internists and 77% of geriatricians agreed with this statement (p=0.03). Sixty three percent of electrophysiologists, 45% of cardiologists, 33% of internists, and 55% of geriatricians believed patients knew they could deactivate their ICD (p=.11). One potential barrier to ICD deactivation discussions may relate to physician’s beliefs that they can predict which patients will receive a shock. In reality it can be difficult to predict the terminal cardiac rhythm. Physicians who believe they can predict who will be shocked may fail to discuss deactivation with patients for whom they mistakenly believe ICD firing is unlikely. Clinicians may be unaware of patients’ understanding about their devices. Most clinicians in every group believed their patients understood the indication for their device, which might limit their belief that more discussion is needed. Data from patient focus groups, however, reveal that they do not know the indication for their device and that their understanding of its purpose varies widely and is often inaccurate.(2) A final barrier may be that many physicians (in our study 1/3 of internists and 2/3 of electrophysiologists) believed that patients already knew they could deactivate the shocking function of their ICD. Prior data suggest that patients with ICDs often do not know that this is possible.(2) Clinicians who believe that patients know the options for device management at the end of life may be less likely to have deactivation conversations. This study has limitations. The rate of surveys completed was less than 50%. Nevertheless, our enrollment rate is consistent with other clinician surveys reporting on patients with advanced illness.(5) Electrophysiologists were more likely to respond as compared to others: perhaps because they take more “ownership” of the issue of deactivation because it involves a device they implant. This study identifies clinician perceptions that may reflect barriers to communication about deactivation of ICDs in patients with advanced illness. The focus of this work is on barriers to conversations as we believe that these conversations should occur as part of conversations about advance care planning; whether the device is deactivated is the decision of the patient and family. Because patients with ICDs are cared for by physicians of a variety of specialties with differing views, future interventions to improve conversations about device deactivation should be targeted at both specialists and generalists with the appropriate timing of these conversations determined by subsequent empirical studies.

Trajectory of End-Stage Heart Failure: The Influence of Technology and Implications for Policy Change

Patients with end-stage heart failure have a trajectory of illness characterized by an overall gradual decline in function punctuated by periods of symptom exacerbation followed by a return nearly to their baseline. These exacerbations are not predictable. Death may come suddenly and unexpectedly for each patient, even though predictive models can draw an accurate survival curve by averaging the experience of a substantial number of people with heart failure. Heart failure patients often have treatable symptoms, such as dyspnea, fatigue, and generalized pain. In this article, we explain the trajectory of patients with heart failure, illustrate the importance of advance care planning for these patients, discuss the impact of choices to use or forgo new technologies, and suggest ways to improve the care system. Only by reexamining our health care spending priorities can we create a sustainable care system that allows patients to live both long and comfortably, reaching a balance that serves them and their communities well.

The Intersection Between Geriatrics and Palliative Care: A Call for a New Research Agenda

Palliative care is interdisciplinary treatment focused on the relief of suffering and achieving the best possible quality of life for patients and their caregivers. It differs for geriatric patients from what is usually appropriate in a younger population because of the nature and duration of chronic illness during old age. In spite of the fact that death occurs far more commonly in older people than in any age group, the evidence base for palliative care in older adults is sparse. Over the coming years, the research foci in the field of geriatrics and palliative care that must be addressed include establishing the prevalence of symptoms in patients with chronic disease; evaluating the association between treatment of symptoms and outcomes; increasing the evidence base for treatment of symptoms; understanding psychological well‐being, spiritual well‐being, and quality of life of patients and elucidating and alleviating sources of caregiver burden; reevaluating service delivery; adapting research methodologies specifically for geriatric palliative care; and increasing the number of geriatricians trained as investigators in palliative care research. This article discusses specific methods to improve the current situation within each of these seven areas.

Palliative Care for Patients With Head and Neck Cancer: “I Would Like a Quick Return to a Normal Lifestyle”

Head and neck cancers constitute a diverse group of diseases including malignancies of the oral cavity, oropharynx, larynx, sinuses, and skull base. Treatment of these cancers includes a combination of surgical resection, chemotherapy, and radiation. Due to both the patterns of disease recurrence and the adverse effects of treatments, patients with head and neck cancer often have a complex and prolonged course of illness that is marked by periods of freedom from disease and symptoms interspersed with bouts of serious illness, debility, and numerous physical and psychological symptoms including pain, dysphagia, weight loss, disfigurement, depression, and xerostomia. Thus, management of this disease is best provided by an interdisciplinary team that includes individuals from the disciplines of otolaryngology, palliative care, radiation oncology, oncology, nutrition, speech, and physical and occupational therapy. Using the case of Mr K, we describe the symptoms encountered by patients with head and neck cancer and suggest options for management. We discuss the psychological aspects that affect these patients, including issues such as changes in body image, quality of life, anxiety, and guilt. Finally, we discuss the importance of the interdisciplinary team in the care of these patients and outline the roles of each team member. By providing comprehensive care to patients with malignancies of the head and neck, clinicians can increase the likelihood that patients and their families will be able to obtain the best possible outcomes and quality of life.

Titrating guidance: a model to guide physicians in assisting patients and family members who are facing complex decisions.

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but, as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choice between death and long-term debility, neither of which is an acceptable outcome. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. Herein, we present a new paradigm that demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patients outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we propose a 5-step model for physicians with which they can (1) determine at which point the patient is on our model; (2) identify the cognitive factors and preferences for outcomes that affect the decision-making process of the patient and his or her family; (3) reflect on their own reaction to the decision at hand; (4) acknowledge how these factors can be addressed in conversation; and (5) guide the patient and his or her family in creating a plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.