Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records

Abstract

Background: The implantable cardioverter defibrillator (ICD) might give unwanted shocks in the last month of life. Guidelines recommend deactivation of the ICD prior to death. Aims: The aims of this study were to examine trends in time (2007–2016) in how and when decisions are made about ICD deactivation, and to examine patient- and disease-related factors which may have influenced these decisions. In addition, care and ICD shock frequency in the last month of life of ICD patients are described. Methods: Medical records of a sample of deceased patients who had their ICD implanted in 1999–2015 in a Dutch university ( n = 308) or general ( n = 72) hospital were examined. Results: Median age at death was 71 years, and 88% were male. ICD deactivation discussions increased from 6% for patients who had died between 2007 and 2009 to 35% for patients who had died between 2013 and 2016. ICD deactivation rates increased in these periods from 16% to 42%. Presence of do-not-resuscitate (DNR) orders increased from 9% to 46%. Palliative care consultations increased from 0% to 9%. When the ICD remained active, shocks were reported for 7% of patients in the last month of life. Predictors of ICD deactivation were the occurrence of ICD deactivation discussions after implantation (OR 69.30, CI 26.45–181.59), DNR order (OR 6.83, CI 4.19–11.12), do-not-intubate order (OR 6.41, CI 3.75–10.96), and palliative care consultations (OR 8.67, CI 2.76–27.21) Conclusion: ICD deactivation discussions and deactivation rates have increased since 2007. Nevertheless, ICDs remain active in the majority of patients at the end of life, some of whom experience shocks.

Implantable cardioverter defibrillator deactivation and advance care planning: a focus group study

“…Little research has been conducted on the experiences of ICD patients with ACP conversations about ICD deactivation. Although international expert consensus statements recommend to timely and frequently discuss ICD deactivation with the patient,1 recent studies show these conversations are scarce 2. Several patients in our study indicated that their healthcare providers are capable regarding medical-technological issues, but felt there was not always the opportunity to discuss topics with an emotional component, such as the end-of-life.…”

“…The implantable cardioverter defibrillator (ICD) treats potentially lethal arrhythmias by either antitachycardia pacing or delivering an electrical shock 1. About half of ICD patients experience potentially painful shocks during their life 2. The number of ICD patients has grown, as the indication for implantation has been extended from secondary to primary prevention 3.…”

“…ACP enables individuals to define and discuss goals and preferences for future medical treatment and care, and to record and review these if appropriate 9. Previous studies have shown that only a minority of patients (27% in a study from 2004,10 up to 35% in a study from 20182) had discussed ICD deactivation with their healthcare professional and had their ICD deactivated prior to death 2 11. It is unknown why ICD deactivation is infrequently discussed, and what patients would want with their device when approaching the end-of-life.…”

Unmet device reprogramming needs at the end of life among patients with implantable cardioverter defibrillator: A systematic review and meta-analysis

“…Five studies included patients treated before the recommendations were published in 2010. 16,18,21,23,28 They reported lower reprogramming prevalence (pooled proportion prevalence of 20%, 95% CI: 16%-25%) than articles evaluating the outcome after 2010 (pooled proportion prevalence of 40%, 95% CI: 32%-49%). 24,28,29 Two studies included patients treated both before and after 2010 and presented the results separately.…”

“…16,18,21,23,28 They reported lower reprogramming prevalence (pooled proportion prevalence of 20%, 95% CI: 16%-25%) than articles evaluating the outcome after 2010 (pooled proportion prevalence of 40%, 95% CI: 32%-49%). 24,28,29 Two studies included patients treated both before and after 2010 and presented the results separately. Kinch Westerdahl et al 29 conducted a study in 2019 that included 341 patients from more than 60 hospitals in Sweden and reported the prevalence of implantable cardioverter defibrillator reprogramming at the end of life among patients who died between 2003 and 2010 (34%) and the prevalence of reprogramming among patients who died in 2014 (52%).…”