Patient Expectations From Implantable Defibrillators to Prevent Death in Heart Failure

Stewart, Garrick C.; Weintraub, Joseph R.; Pratibhu, Parakash; Semigran, Marc J.; Camuso, Janice; Brooks, Kimberly; Tsang, Sui; Anello, Mary Susan; Nguyen, Viviane; Lewis, Eldrin F.; Nohria, Anju; Desai, Akshay S.; Givertz, Michael M.; Stevenson, Lynne Warner

doi:10.1016/j.cardfail.2009.09.003

Cited by 115 publications

(122 citation statements)

References 51 publications

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“…In fact, a number of complications related to implantation and device activation have been described with the use of both devices. [7,31] Major complications include inappropriate shocks, device infection, lead malfunction and complications related to extraction of devices. [25] A harmful effect related to CRT has been found in patients with a QRS duration < 130 msec.…”

Section: Crtmentioning

confidence: 99%

Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in the Treatment of Heart Failure with Reduced Ejection Fraction

Spoletini¹,

Coats²

2017

ICFJ

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It has been long acknowledged that electrical-conduction disturbances may be both a cause of heart failure and a consequence of it. In fact, many patients with heart failure have an asynchronous contraction pattern of the heart muscle that further reduces the heart ability to pump blood. Electrical disturbances may therefore result in progressive left ventricular dysfunction, due to the added effects of HF-related electrical dyssynchrony. For this reason, device therapy may play a key role in the management of patients with heart failure and reduced ejection fraction (HFrEF). In particular, Implantable Cardioverter- Defibrillators (ICD) and Cardiac Resynchronization Therapy (CRT) may improve ejection fraction by reestablishing mechanical synchrony, possibly reversing symptoms and signs of heart failure, in addition to the more obvious role of ICD in terminating ventricular arrhythmias that threaten sudden death. Recommendations on device therapy from the current guidelines on heart failure management put out by the ESC/HFA in 2016 update our understanding of the evidence base for the use of ICD and CRT in HFrEF. We review these recommendations and the evidence behind them.

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Section: Crtmentioning

confidence: 99%

Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in the Treatment of Heart Failure with Reduced Ejection Fraction

Spoletini¹,

Coats²

2017

ICFJ

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“…5 It is unclear how possible benefits and harms are communicated to patients during the clinical encounter and how patients make sense of this information. Indeed, data on patients' expectations of ICDs suggest that survival benefits might be substantially overestimated, 21 and improvements to how information on the clinical rationale for ICDs (including the fact that simple ICDs do not confer any symptom or quality-of-life benefits) is communicated to patients and their relatives may be warranted. It has been shown that patients eligible for different therapies might not be fully aware of the benefits and harms of each option, 15,16 and the psychosocial impacts of available treatment or management options rarely feature in risk communication.…”

Section: Structure Of the Reportmentioning

confidence: 99%

A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

Standing

Exley

Flynn

et al. 2016

Health Serv Deliv Res

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Background Implantable cardioverter defibrillators (ICDs) are recommended for patients at high risk of sudden cardiac death or for survivors of cardiac arrest. All ICDs combine a shock function with a pacing function to treat fast and slow heart rhythms, respectively. The pacing function may be very sophisticated and can provide so-called cardiac resynchronisation therapy for the treatment of heart failure using a pacemaker (cardiac resynchronisation therapy with pacemaker) or combined with an ICD [cardiac resynchronisation therapy with defibrillator (CRT-D)]. Decision-making about these devices involves considering the benefit (averting sudden cardiac death), possible risks (inappropriate shocks and psychological problems) and the potential need for deactivation towards the end of life. Objectives To explore patients’/relatives’ and clinicians’ views/experiences of decision-making about ICD and CRT-D implantation and deactivation, to establish how and when ICD risks, benefits and consequences are communicated to patients, to identify individual and organisational facilitators and barriers to discussions about implantation and deactivation and to determine information and decision-support needs for shared decision-making (SDM). Data sources Observations of clinical encounters, in-depth interviews and interactive group workshops with clinicians, patients and their relatives. Methods Observations of consultations with patients being considered for ICD or CRT-D implantation were undertaken to become familiar with the clinical environment and to optimise the sampling strategy. In-depth interviews were conducted with patients, relatives and clinicians to gain detailed insights into their views and experiences. Data collection and analysis occurred concurrently. Interactive workshops with clinicians and patients/relatives were used to validate our findings and to explore how these could be used to support better SDM. Results We conducted 38 observations of clinical encounters, 80 interviews (44 patients/relatives, seven bereaved relatives and 29 clinicians) and two workshops with 11 clinicians and 11 patients/relatives. Patients had variable knowledge about their conditions, the risk of sudden cardiac death and the clinical rationale for ICDs, which sometimes resulted in confusion about the potential benefits. Clinicians used various metaphors, verbal descriptors and numerical risk methods, including variable disclosure of the potential negative impact of ICDs on body image and the risk of psychological problems, to convey information to patients/relatives. Patients/relatives wanted more information about, and more involvement in, deactivation decisions, and expressed a preference that these decisions be addressed at the time of implantation. There was no consensus among clinicians about the initiation or timing of such discussions, or who should take responsibility for them. Introducing deactivation discussions prior to implantation was thus contentious; however, trigger points for deactivation discussions embedded within the pathway were suggested to ensure timely discussions. Limitations Only two patients who were prospectively considering deactivation and seven bereaved relatives were recruited. The study also lacks the perspectives of primary care clinicians. Conclusions There is discordance between patients and clinicians on information requirements, in particular the potential consequences of implantation on psychological well-being and quality of life in the short and long term (deactivation). There were no agreed points across the care pathway at which to discuss deactivation. Codesigned information tools that present balanced information on the benefits, risks and consequences, and SDM skills training for patients/relative and clinicians, would support better SDM about ICDs. Future work Multifaceted SDM interventions that focus on skills development for SDM combined with decision-support tools are warranted, and there is a potential central role for heart failure nurses and physiologists in supporting and preparing patients/relatives for such discussions. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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“…The patient's wishes for his or her ICD should be addressed as part of the routine discussion of goals of care and resuscitation status. Many will choose to keep the device active 167,[171][172][173][174] ; however, it is appropriate to identify a future time when deactivation would be desired. Staff should identify the cardiology team managing the device.…”

Section: Management Of Cardiac Implantable Electronic Devices In Hf Pmentioning

confidence: 99%

Heart Failure Management in Skilled Nursing Facilities

Jurgens¹,

Goodlin²,

Dolansky³

et al. 2015

Circ: Heart Failure

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655H eart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age.1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. 2,3Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities.Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. [4][5][6] Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. 7Transitions between hospitals and SNFs may be problematic. 8SNF 30-day rehospitalization rates for HF range from 27% to 43%, 7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death.11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patientcentered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. MethodsThis scientific statement on HF management in SNFs was developed by a writing group of experts representing nursing, medicine (cardiology, geriatrics, nursing home physicians, and palliative medicine), pharmacology, physical therapy, dietary clinical management, research, and quality of care. Sponsors (the American Heart Association [AHA] and the Heart Failure Society of America) identified specific members of the writing group, and others were selected on the basis of known expertise. A literature search was performed using the key The current document is solely the responsibility of the authors and does not represent the official views of the National Heart, Lung, and Blood Institute or the Department of Health and Human Services.The American Heart Association and the Heart Failure Society of America make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.This document was approved by the American Heart Association Science Advisory and Coordinating Committee on September 15, 2014, and by the...

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Patient Expectations From Implantable Defibrillators to Prevent Death in Heart Failure

Cited by 115 publications

References 51 publications

Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in the Treatment of Heart Failure with Reduced Ejection Fraction

Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in the Treatment of Heart Failure with Reduced Ejection Fraction

A qualitative study of decision-making about the implantation of cardioverter defibrillators and deactivation during end-of-life care

Heart Failure Management in Skilled Nursing Facilities

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