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Palliative Care in Cardiac Electrophysiology

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Essentials of Palliative Care

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Abstract

Rapid advances in the field of cardiac electrophysiology have led to the therapies that offer the opportunity of increased survival, as well as improved quality of life. As a result, palliative care issues are becoming increasing common in patients with cardiac rhythm disturbances. Knowledge of the available therapies and their indications can aid in palliative care decisions in selected patients.

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Author information

Authors and Affiliations

  1. Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA

    Eric Grubman M.D.

Authors
  1. Eric Grubman M.D.
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Corresponding author

Correspondence to Eric Grubman M.D. .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Yale University, New Haven, 06520, Connecticut, USA

    Nalini Vadivelu

  2. Citrus Road 278, River Ridge, 70123, Louisiana, USA

    Alan David Kaye

  3. Keck School of Medicine, Department of Anesthesiology, Pain Medic, of the University of Southern California, Los Angeles, 90035, California, USA

    Jack M. Berger

Appendices

Review Questions

  1. 1.

    An 85-year-old woman with a previously implanted biventricular defibrillator is receiving palliative care, due to metastatic colon cancer. She is competent to make decisions regarding her care. She asks to have her ICD “turned off.” You inform her that it would be appropriate to:

    1. (a)

      Deactivate the defibrillation features of the device only

    2. (b)

      Deactivation of biventricular pacing functions of the device only

    3. (c)

      Deactivation of rate responsive pacing functions of the device only

    4. (d)

      Deactivation of all pacing functions only

    5. (e)

      All of the above are appropriate

  2. 2.

    A 75-year-old man with ALS is receiving palliative care. He develops complete heart block, which results in recurrent syncope and severe dizziness. As his clinician, you inform him that:

    1. (a)

      Permanent pacemaker implantation is reasonable, given the symptomatic nature of his bradyarrhythmia

    2. (b)

      There is no role for pacemaker implantation in patients receiving palliative care

    3. (c)

      Temporary pacemaker implantation, which can be maintained for several days, is the most appropriate therapy for his arrhythmia

    4. (d)

      External pacing, though uncomfortable, is the most appropriate therapy for his arrhythmia

  3. 3.

    A 68-year-old woman has a previously implanted pacemaker, for the treatment of complete heart block. She would be asystolic without the pacemaker. She is receiving palliative care for metastatic pancreatic cancer. Her pacemaker battery has weakened to the point that the device should be changed. She is no longer making her medical decisions, but her daughter, who has assumed this role, asks that the pacemaker not be changed. She understands that this will likely lead to the patient’s death. You should inform her that:

    1. (a)

      Pacemaker generator change is minimally invasive, and must be performed, as the therapy is vital

    2. (b)

      Pacemaker generator change must be performed, as it is considered “continuation of existing therapy” and is not part of palliative care decisions

    3. (c)

      It is appropriate not to replace the pacemaker, as long as the daughter understands the implications

    4. (d)

      Pacemaker generator change must be performed, as the decision not to replace the pacemaker can only be made by the patient, not her daughter

  4. 4.

    A 90-year-old man is receiving palliative care, due to severe, advanced dementia. He presents to the Emergency Room with newly a urinary tract infection. He is incidentally noted to have atrial fibrillation. He is hemodynamically stable. The most appropriate therapy for his atrial fibrillation would be:

    1. (a)

      Electrical cardioversion, followed by initiation of amiodarone therapy

    2. (b)

      Electrical cardioversion, without long-term antiarrhythmic drug therapy

    3. (c)

      Begin the patient on flecainide, with the hopes that it will restore normal sinus rhythm, without the use of electrical cardioversion

    4. (d)

      No further therapy is warranted, as the patient is asymptomatic

  5. 5.

    In patients receiving palliative care, ablation therapy for SVT:

    1. (a)

      Is not appropriate

    2. (b)

      Can be reasonable, if the arrhythmia is symptomatic and frequent

    3. (c)

      Can be reasonable, if they can be accomplished with minimal risk

    4. (d)

      Can be reasonable, only if they are likely to be life-saving

Answers

  1. 1.

    (e) All of the above are appropriate

  2. 2.

    (a) Permanent pacemaker implantation is reasonable, given the symptomatic nature of his bradyarrhythmia

  3. 3.

    (c) It is appropriate not to replace the pacemaker, as long as the daughter understands the implications

  4. 4.

    (d) No further therapy is warranted, as the patient is asymptomatic

  5. 5.

    (b) Can be reasonable, if the arrhythmia is symptomatic and frequent

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Grubman, E. (2013). Palliative Care in Cardiac Electrophysiology. In: Vadivelu, N., Kaye, A., Berger, J. (eds) Essentials of Palliative Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5164-8_22

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  • DOI: https://doi.org/10.1007/978-1-4614-5164-8_22

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-5163-1

  • Online ISBN: 978-1-4614-5164-8

  • eBook Packages: MedicineMedicine (R0)

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