Implantable cardioverter defibrillators at the end of life: future perspectives on clinical practice

Abstract

The implantable cardioverter defibrillator (ICD) is effective in terminating life-threatening arrhythmias. However, in the last phase of life, ICD shocks may no longer be appropriate. Guidelines recommend timely discussion with the patient regarding deactivation of the shock function of the ICD. However, research shows that such conversations are scarce, and some patients experience avoidable and distressful shocks in the final days of life. Barriers such as physicians’ lack of time, difficulties in finding the right time to discuss ICD deactivation, patients’ reluctance to discuss the topic, and the fragmentation of care, which obscures responsibilities, prevent healthcare professionals from discussing this topic with the patient. In this point-of-view article, we argue that healthcare professionals who are involved in the care for ICD patients should be better educated on how to communicate with patients about ICD deactivation and the end of life. Optimal communication is needed to reduce the number of patients experiencing inappropriate and painful shocks in the terminal stage of their lives.

Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association

“…Withholding and withdrawing cardiac therapeutic supports are generally deemed ethically equivalent under conditions where a death is foreseeable because of underlying disease or where a patient with capacity and decisional authority (may be age-based legally) does not wish to receive the intervention or therapy. [107][108][109][110][111][112] The extension of discontinuation of life-sustaining therapies beyond ventilator support or critical care therapies to implantable cardiac defibrillators, [112][113][114][115][116][117] ECMO, [117][118][119][120][121] or ventricular assist devices (VADs) 122,123 is predicated on the same ethical justifications and legal permissions. Implantable cardiac defibrillator deactivation is suggested to decrease additional harm and distress by multiple induced shocks from a defibrillator device at the EOL.…”

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

“… 61 Similar dilemmas occur when Implantable cardioverter-defibrillator devices are used, as distressful shocks may no longer be appropriate in the last phase of life. 62 In such a scenario, conversations regarding the deactivation of the device are necessary. The principle of acting always in the patient's “best interests” must be adhered to.…”