, a very good question: When during the dying process do you turn off your heart defibrillator? A new study in the Annals of Internal Medicine examines the challenge of deactivating heart defibrillators in the dying:
Carol Filak had heard about painful, repeated shocks that people sometimes experience from those implants in their final days. So when her father, Joseph Hoffman, was diagnosed with terminal cancer, she asked at his cardiologist's office: What about the defibrillator he'd had implanted years earlier? It's too soon to worry about, she was told.
Two months later, Hoffman, 81, entered hospice care in his West Orange, N.J., home and still Filak had to make numerous calls to the cardiologist before someone arrived to deactivate the defibrillator. "You need to be told that this is something that's not going to prolong his life," says Filak. "When he died, it was a very peaceful death."
It's not unusual for health professionals to avoid the topic, says Dr. Nathan Goldstein of New York's Mount Sinai Medical Center. His research, published this month in Annals of Internal Medicine, suggests most hospices — expert in end-of-life care — aren't making defibrillator decisions part of their routine. Nearly 60 percent of hospices he examined had at least one patient shocked within the past year, sometimes multiple times at once. Yet just one in 20 hospices had a method even to identify who harbored the implant when they entered the program.
But with more than 100,000 implantable cardioverter-defibrillators, or ICDs, inserted every year, more and more families like Filak's will face the question.
"We're trained to save, save, save, cure, cure, cure," says Goldstein, who has studied end-of-life defibrillation since seeing a dying lung cancer patient brought to the emergency room because his implant kept firing. "There are some folks we can't cure. We have to make them as comfortable as possible."
I like this issue because in many ways it forces us to face the challenge of dying in a world where technology has solved many functionality problems but has only complicated the definition of death. Once was a time where death meant the rather simultaneous cessation of breathing, heart beat and brain function. But technology can now sustain the former two almost indefinitely with respirators and defibrillators. Terri Schiavo's heart, for instance, was shocked back into operation by paramedics when she was found after her collapse. For the first few years she was kept breathing by a respirator, then was slowly weaned from it. But her lack of brain function remained. What does death mean now?
As the discussion regarding defibrillators in the dying comes to the fore, necessarily, I think it helps us to clarify what is meant by prolonging life and prolonging death.
Labels: defibrillators, end of life care, hospice, over-treatment, prolonging death