New Study Underscores Need for Palliative Care

Annals of Internal Medicine Says Physicians Rarely Discuss Defibrillator Use with Their Sickest Patients

A new study showing doctors rarely discuss the pros and cons of continuing to use implanted defibrillators with their sickest patients underlines the need for more palliative care consultations, which have been shown to improve physician-patient communication and provide more patient-centered care.

The study, "Management of Implantable Cardioverter Defibrillators in End-of-Life Care", published December 7 in Annals of Internal Medicine, found the lack of physician-patient communication meant that patients underwent repeated defibrillator shocks during the last days, hours or minutes of life as they were dying. At this late stage of life, defibrillation shocks cause discomfort, anxiety and a prolonged death. Defibrillators are surgically placed inside a patient’s chest to provide ongoing heart rhythm monitoring and stand-by-intervention, and they automatically shock the heart during a cardiac arrest or irregular heartbeat.

"Among patients with heart failure and months - years to live, defibrillators save thousands of lives. However, this study makes clear that physicians should talk about the pros and cons of continuing the device when patients are approaching the last days to weeks of life", said Nathan Goldstein, MD, Assistant Professor, Brookdale Department of Geriatrics and Adult Development at Mount Sinai School of Medicine and lead investigator on the study. "These are difficult and complex conversations and physicians may find it useful to request a palliative care consultation to address this sensitive issue, develop a clear plan of care and improve seriously ill patients' quality of life", he said.

Co-authors Dr. Goldstein and Joanne Lynn, MD, MA, MS, said the study found that physician-patient discussions about deactivating defibrillators took place in only 27 of 100 cases of terminally ill patients at Yale-New Haven Hospital, New Haven, Connecticut. Even among patients with do-not-resuscitate orders, discussions about continued use of the device occurred in fewer than 45 percent of the cases.

Next of kin reported that more than one-quarter of the 100 patients received a shock from the defibrillator in the last month of life, and 30 percent of that group received a shock in the last minutes of life. Among the 27 discussions that occurred about defibrillators, 21 patients or family members decided to deactivate the device. Most of the deactivations occurred in the days, hours or minutes before the patients died.

Diane E. Meier, MD, FACP, Director of the Center to Advance Palliative Care (CAPC), and a leading expert on palliative care, said the lack of physician-patient communication shown in the study is not restricted to patients with defibrillators. "This is a common problem, because of the intense time pressures on physicians and the absence of the health care systems necessary to treat people with serious and complex illness."

"CAPC is working with hospitals around the country to address these challenges and the complex physician-patient communication highlighted in this new study. Palliative care is needed now more than ever to maximize the patient's quality of life and control. We need to ensure a systematic approach to physician-patient communication and medical decision-making about all medical technologies, including use of defibrillators."

Palliative care teams provide high-quality, effective management of debilitating chronic disease and life-threatening illness. The specialty focuses on intensive communication with patients and families, coordinating care among specialists and relieving suffering and improving a patient's quality of life at all stages of illness, including during curative and life-prolonging treatment. U.S. News & World Report uses the presence of a palliative care program as an important criterion for ranking America’s best hospitals.

The study, "Management of Implantable Cardioverter Defibrillators in End-of-Life Care," was funded by the Robert Wood Johnson Foundation and the Department of Veterans Affairs and conducted at Yale-New Haven Hospital, where Dr. Goldstein was previously a research fellow.

The Center to Advance Palliative Care, a Robert Wood Johnson Foundation-funded initiative, provides hospitals with the tools, technical assistance and training at Palliative Care Centers of Excellence to start palliative care programs. For more information, visit the CAPC website at www.capc.org.

CONTACT: Lisa Morgan, LDM Strategies, 212-924-6182 or [email protected].