Hospital mortuary visits to deactivate ICD shock therapies in deceased patients during the COVID-19 pandemic
The BHRS have received enquiries from members asking for recommendations on mortuary visits for ICD therapy deactivation during the COVID-19 pandemic. The BHRS council have developed this questions and answers guide to help members, services and the wider CRM community with this enquiry.
It must be acknowledged that the information provided is specific to this task during the COVID-19 pandemic. Recommendations made are based on best clinical judgment at the time of publishing and advice may change over time as the pandemic progresses and hospital conditions, services and staffing levels change.
It remains critical to avoid unnecessary shocks at the end of life when death is expected. Therefore, for patients in hospital or on ITU where death is expected it remains vital to deactivate ICD therapies or at least disable the device with a magnet if this is not possible or death is more imminent. However, devices are only temporarily deactivated by magnets, and there will always be unexpected deaths in the community where devices have not been deactivated, hence thought must be given to subsequent issues of deactivating ICD therapies and device removal.
Should device services provide staff to visit the hospital mortuary for ICD therapy deactivation?
Ideally yes. Deceased patients with implantable cardiac defibrillators (ICD) in situ who are to be cremated or in the rare event of a post mortem (PM) will require deactivation of ICD shock therapies. This is because the ICD will need to be removed by clinical or mortuary personnel prior to cremation or as part of the PM. If the device is not deactivated prior to removal there is a risk of electric shock to these staff groups1. ICDs must be removed prior to cremation as the contained battery components if heated may cause an explosion. Cutting the leads in a device that has not been deactivated risks shocks to the operator and is also a danger during subsequent storage.
Is there an alternative to device deactivation if our department cannot offer this service at the current time?
It is possible for devices to be safely removed without deactivation, but this requires a magnet being held over the device throughout the process and the us of a hex wrench to release the leads from the generator. A protocol has been developed for this by the Newcastle upon Tyne Arrhythmia Group which can be read here.
Under normal circumstances ICDs are often removed by either mortuary staff or undertakers. Either could perform this safely using such a protocol, but it would be essential to have the necessary equipment to do so safely.
Is consent required for removal of ICD or pacing devices?
The HTA regulates legal issues pertaining to the deceased in mortuaries. The HTA have kindly clarified for us on 7th April 2020 that The HTA does not cover removal of medical devices post mortem. However, the HTA have issued a standards and guidance document for Post-Mortem examination which covers invasive procedures such as the removal of implanted devices. This guidance states that permission from the family for removal of pacemakers etc. should be obtained but does not specify how permission is to be obtained.
Firstly, this means permission could well be verbal or by phone and does not need to be written consent. Secondly, the wording is that permission ‘should’ be obtained which would be good routine practice. It is not a requirement though, and there are reasons why one might not, e.g. uncertainty over next of kin, difficulty contacting them, or time constraints during a national emergency requiring rapid processing of the deceased. Clearly there are problems and risks to holding the deceased for prolonged periods at a time when mortuaries may be very busy. It is therefore worth noting that permission for removal of these devices is not essential.
Do patients with ICDs going for burial require ICD therapy deactivation?
Ideally devices would be deactivated prior to burial, firstly in case there are changes in plans, and secondly to avoid the small risk of upsetting families with devices alarming from inside the deceased/coffins. However, ICD deactivation is not a requirement for burial. Therefore cardiac departments may decide not to offer this service at present. If the device is not deactivated it should be well documented that ICD therapies are programmed on in case there is a change in process.
Is it safe to visit the mortuary to turn off ICD therapies in deceased patients?
Yes, if one follows the necessary precautions. There is small risk to staff attending the mortuary from contact with the deceased (minimal) and contact with mortuary staff2. This risk can be minimised by wearing personnel protective equipment (PPE), keeping time spent with the deceased to a minimum and adhering to the 2m social distancing guidance. Level or PPE should be guided by Public Health England recommendations3, in this instance PPE should include disposable gloves, a disposable apron and a surgical mask. It is unlikely that eye protection will be required unless the body is exposed. It is recommended to ask the mortuary team to keep the deceased covered and if practicably possible request the deceased is placed in an available room such as a chapel or viewing room to reduce the need to enter the main mortuary area.
Who can perform ICD therapy deactivation?
ICD therapy deactivation should be performed by an appropriately trained person. This will most commonly be a device trained cardiac physiologist but could be a device trained specialist registrar or Device/EP Consultant.
What should I take when visiting the mortuary to deactivate ICD therapies?
It is recommended to prepare for the visit and take as little as possible. An item list may include a trolley if required, the identified ICD manufacturer programmer and cleaning materials such as SaniCloth wipes or a suitable alternative, to wipe down items prior to leaving the area. A sterile sheath if available may also be useful for the programmer wand and cable if telemetry requires the wand to be in contact with the deceased chest, which could be disposed of post deactivation.
Should we offer home visits to deactivate ICD therapies?
Centres with established protocols to provide home visits may choose to continue to offer this service to patients requesting community-based ICD deactivation. These centres should err on the side of caution and local protocols should be revised to include a risk assessment with respect to preventing COVID-19 infection and transmission, use of PPE, minimal levels of equipment and methods of equipment cleaning required.
Where this service is not normally provided, or cannot be offered in the current circumstances, it is suggested that a magnet be sent out with instructions for use if it is an emergency and it is expected that the end of life is within a few days. Where it is anticipated that the patient will survive longer than this it may be possible for departments to coordinate a patient visit to a local hospital where ICD therapies can be deactivated safely by the cardiac rhythm management team, whilst still taking the necessary precautions to reduce the risk of COVID-19 infection and transmission.
- Medicines and Healthcare products Regulatory Agency. Implantable cardioverter defibrillators (ICDs) – disable all high voltage shock therapies before you remove ICD. https://www.gov.uk/drug-device-alerts/medical-device-alert-implantable-cardioverter-defibrillators-icds-disable-all-high-voltage-shock-therapies-before-you-remove-icd December 2014.
- Royal College of Pathologists and the Association for Anatomical Pathology Technology in conjunction with Public Health England. Transmission based precautions. Guidance for care of deceased during COVID-19 pandemic. 19th March 2020.
- Public Health England. PHE Guidance COVID-19 personal protective equipment (PPE) Updated. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe 6 April 2020.