The Importance of Pre-Procedure Discussions: Communication Between Patient and Physician and the Development of a Device Management Plan

Much has been written about the positive benefits of communication between patient and physician. Today, in the increasingly time-pressured medical work environment, physicians are pushed to see more patients in less time. Patients are moved thru clinics as if on an assembly line. There are fewer opportunities for conversation and many patients and providers never really get to know each other on a “human” and interpersonal level. Care often suffers due to the fact that the patient and provider are unable to really connect. The connection that develops when patient and clinician are afforded the ability to spend adequate time in consultation leads to a collaborative approach to disease management. Sadly, this is lacking in medicine today.

I recently blogged about the psychological effects of ICD recalls. In that blog I mentioned my use of Shock and Recall Plans with my patients in an effort to ease anxiety when these events do inevitably happen. I was fortunate enough to have comments and questions concerning these plans left by several highly engaged readers (some of which are ICD patients). This blog entry is in response to those inquiries. Much of my “plans” have been inspired by Dr Sam Sears who has done pioneering work in this arena.

Those of us who perform invasive procedures as a routine part of our practice are quite accustomed to having the obligatory “informed consent” conversations with our patients. There are legal and national standards for these conversations as well as institution-specific requirements. We must explain the procedure to the patient in words he or she can understand, we must explain the alternatives to the procedure and carefully go over the possible complications. After this discussion is completed, we must have the patient sign a legal document that verifies their understanding of the procedure they have just agreed to. Is this type of discussion applicable to any procedure? Is this discussion adequate? Is this truly informed consent? I would argue “No”. I would put forward the fact that we must go a step further, we must individualize consent and we must have discussions that address specific concerns that may be attributable to a particular procedure such as ICD implantation. For me, a key component in this discussion is to develop a Shock and Recall Plan.

What is a shock plan? Quite simply, a “shock plan” is a procedure that the patient and physician create to address what to do in the event of an ICD shock. A “recall plan” is a similar construct. In Circulation in 2005, Dr Sears et al. published a guideline for responding to shocks and developed a suggested plan. The plan consists of several parts:

1. Patient education: The patient should know as much as possible about their device. Access to data is paramount.

2. Data Control: Patient needs to have all relevant data in one place –device name and serial number, physician name and number, after hours on call numbers, list of medications and medical problems. ALL in one PLACE. Give a duplicate copy of this information to a friend or family member as well.

3. Action plan: This plan should be rehearsed and discussed with family. The Shock plan should be developed collaboratively. An example of a plan of action may be: Receive a shock > Feel fine > Call MD or transmit remote report OR Receive shock > Experiencing chest pain, SOB or other symptoms > Call 911 and seek medical attention. These plans may be individualized and reflect the particular needs of the patient. In addition, coping strategies for dealing with shocks can be discussed and rehearsed. These may include breath work, positive thinking and certainly post shock debriefing

A recall plan has very similar structure. Dr Sears published a manuscript in Circulation in 2009 addressing the Recall plan. Again, the plan is patient specific but centers on Patient education, Access to and control of relevant data, and development of coping strategies to deal with the anxiety related to a device advisory.

The key component in any of these plans is communication. Although not always easy and certainly not always an adequate dialogue, I try to spend time discussing these issues with my patients prior to implantation. Along with explaining the procedure and the possible complications associated with device implantation, I discuss the implications of living with an implanted device-namely shocks and recalls. During these discussions, we focus on the significant life saving benefits of device therapy as well as the downside of shock and recall. When shocks and recalls occur, we revisit these discussions in clinic and remind patients that knowledge and preparedness bring empowerment.

As an Electrophysiologist, I am fortunate to be in a position to provide potentially life saving therapy to my patients. However, with this privilege comes much responsibility. Part of the duty of any physician who performs procedures is to ensure that the patient is fully aware of the risks, benefits and alternatives to any invasive intervention. To meet regulatory requirements, we must provide informed consent at a minimum. To ensure that our patients are able to function at the highest possible levels post operatively, we must also spend time developing strategies to deal with the device implant long term. Communication between physician and patient is of paramount importance. The key to coping with shocks and recalls is simple. Knowledge, Access to Data, and Developing a Plan.

References: (These are “Patient Pages” and can be downloaded and copies placed in your ICD clinic or used in Patient support groups)

How to Respond to an Implantable Cardioverter-Defibrillator Shock Samuel F. Sears, Jr, Julie B. Shea and Jamie B. Conti Circulation 2005, 111:e380-e382

How to Respond to an Implantable Cardioverter-Defibrillator Recall Kari B. Kirian, Samuel F. Sears and Julie B. Shea Circulation 2009;119;e189

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