1. Supporting a dignified death in patients who have an Implantable Cardioverter Defibrillator (ICD)

2. Patients with implantable defibrillators are out there and coming your way
Supporting wellness and independence in older people living with long term conditions is the focus of these two days…however
There will come a time when we will need to use our nursing skills and compassion, to provide support and ensure a
dignified death

3. Heart failure management is difficult with periods of decompensation and periods of relative stability.
How do we know when the end of life is coming?

4. To think about…. When the tablets stop working
More frequent admissions to hospital
Possibly longer length of stay
Patient saying they have had enough
Quality of life deteriorating
This is the time to start talking to the Doctors patient and family.

5. Challenge to each and everyone of you
Go back to your workplace
Identify patients who have an ICD in-situ
Where are they on the life continuum?
Is there a “Flag” highlighting that they have an ICD ?
ICD’s save lives - death at some stage is inevitable.

6. Introducing Case study –A dignified death ICDs –
How they work and save lives.
Controlled and emergency deactivation of the shocking component
The WDHB Guideline on Deactivation

7. Co-Joint Management of a Heart Failure Patient at End of Life Catherine E. Callagher CNS Heart Failure
Cardiologist, GP, CNS Heart Failure Hospice Nurse
Patient, wife and daughter
2012

8. A lovely man March 2012 81 years old Retired school teacher
Enthusiastic lover of life
Wanted to complete the “Bucket List” he and the love of his life, his wife of 50 years, have planned
First on his list …. to drive again!

9. Dilated Cardiomyopathy Left Ventricular Ejection Fraction 10-15% (normal 55%)
ICD inserted August 2011 for non sustained Ventricular Tachycardia
Moderate to Severe Tricuspid Regurgitation
Permanent Atrial Fibrillation
Renal Impairment - Creatinine –
Starr Edwards Mitral Valve Replacement 1992

10. Admissions 14th-19 April 2005 Heart Failure
8th - 10th July Heart Failure
8th - 21st August VT, ICD implanted
2nd - 6th Sept Breathless, Haematoma at ICD insertion site
15th - 16th Sept Atrial Fibrillation and Panic Attacks
15th - 30th Nov Heart Failure
31st Jan - 14th Feb Heart Failure

11. January - April 2012 The last 6 months
Daily contact
Titration of Diuretics
ACE had been stopped secondary to hypotension
Weekly U&E's
Allowed to drive (no VT 6 months)
Cardiologist set clinical parameters
Intensive surveillance to maintain stability

12. May 2012 Physical deterioration- pt cachexic
More unsteady on feet – falls
GP and HF Nurse discuss deterioration
HF Nurse talks to Cardiologist about ICD deactivation at some stage
Cardiologist advises treat symptoms

13. 11 June 2012 Deterioration continues, sleeping a lot of day
Oedema difficult to stabilise
GP discusses referral to Hospice with Pt and wife
Wife calls me crying
I make home visit. I sit on end of their bed and we talk about death, dying and deactivation of ICD - and bucket lists

14. He declined further admission June 2012

15. 12 June 2012 Meeting at pts home
GP, Hospice, Nurse, HF Nurse, Pt and Wife
Pt declines any further interventions
c/o increased abdominal discomfort and dyspnoea
GP and Hospice Nurse organise relevant medications to increase his comfort
HF Nurse to arrange home visit to deactivate ICD – now imperative

16. No More Driving

17. 14 June 2012 Home visit by HF CNS and Cardiology Physiologist
Pt very anxious about deactivation process
Has had no underlying episodes of VT since last check
ICD shocking component deactivated
This is a significant marker that end of life is occurring -

18. HF CNS steps back
Hospice team now leads, initiating appropriate medications and support to pt, wife and daughter
Pt passes away peacefully in his own bed at midnight 17th June 2012
Wife and daughter present
RIP
Never to be forgotten