74
PEER REVIEW: CARDIOLOGY
Deactivation of Implantable Cardioverter Defibrillators in end-of-life situations – more progress needed Lack of discussion around ICD deactivation and subsequent shock therapy in end of life situations is a source of frustration for family members, can be distressing for them, the patient and health care providers. When should discussion happen?
Written by Mr Paul Nolan, Clinical Lecturer & Cardiac Physiologist, Dept of Health and Nutritional Sciences, Atlantic Technological University
Introduction Implantable Cardioverter Defibrillators (ICDs) are a standard therapy to prevent sudden arrhythmic cardiac death. ICDs are proven to reduce mortality in both patients with documented ventricular arrhythmias secondary prevention, and those at risk of such an arrhythmia - primary prevention. An ICD monitors a patient’s heart rhythm and if they develop ventricular tachycardia, of a predetermined rate, or ventricular fibrillation, for typically 30 beats, the device will treat the arrhythmia. This is done in two ways, one a painless fast pacing therapy, called anti-tachycardia pacing (ATP), the other being defibrillation or “shock” therapy. Many of these devices are implanted in patients with heart failure and some of those patients may be implanted with a device which also improves the pumping efficiency of the heart, whilst also having the ability to defibrillate. These devices are referred to as Cardiac Resynchronisation Therapy devices or CRT. The batteries on these devices typically last seven to ten and one of the issues with ICDs is that patient life goals may change, particularly in the setting of the diagnosis of a terminal illness. In this setting a patient may no longer wish to receive painful shock therapy, which may prolong duration, but not quality of life. Given that the number of ICD implants in Ireland is increasing,
at approximately 1000 implants per year, and the duration they may remain implanted means that the number of patients with a terminal illness and an implanted defibrillator is increasing. Despite the fact that consensus documents from the European Heart Rhythm Association1 and the Heart Rhythm Society2 in the US underline the fact that it is ethical, deactivation of shock therapy in ICDs and CRTs remains an issue, with a number of barriers resulting in suboptimal care to patients in end of life situations. Why is this still important? Previous studies have shown that in ICD patients in end of life situations, with a Do Not Resuscitate Order (DNR), over half still had the shock function of their device programmed on. Nearly one quarter of patients had a shock in the last hour of life with over half of these receiving multiple shocks.3 More recent data from 2019 shows similar results with only one-third of patients having the shock function of their device deactivated and 20% of patients having at least one shock within a month of their death.4 It would appear that the consensus documents have not had a significant impact on deactivation rates. A Swedish study5 noted that there was no significant increase in rates of deactivation, likely related to the fact that two-thirds of deaths happened on non-cardiology wards.
AUGUST 2022 • HPN | HOSPITALPROFESSIONALNEWS.IE
The Heart Rhythm Society Consensus document states that discussion around the management of ICDs at end of life should be included as part of the pre-implant discussion but this is only happening in 4% of centres surveyed across Europe.6 One of factors leading to this maybe a healthcare providers perception that such discussion might influence a patient to decline the implant, although the majority of a group of patients interviewed would prefer this to be part of a discussion.7 What we do know is that healthcare providers within cardiology recognise the importance of having the discussion, but that how we currently do it is sub-optimal. There is no consistent approach and that such conversations either do not happen, or happen late in the patient journey.7, 8 One might assume that advance care plans would be a tool which would naturally lead to a discussion around ICD shock deactivation, however the evidence suggests it is not. A systematic review of the literature review showed ICD deactivation was explicitly mentioned in only 1% of advanced directives,9 this is sobering considering that only 12% of heart failure patients even had documented advanced directives.10 The recent COVID-19 pandemic introduced another level of complexity to this issue but also crystalised the importance of when these discussions should happen.11 It is clear that it is best that they happen early in the patient’s ICD pathway, preferably before implant. It should certainly happen when the patient is clinically stable, should be an ongoing in nature but there are also clear identified triggers for discussion which will be outlined below. The requirement for the conversation to be ongoing is highlighted by the fact that
patients remember the benefits of ICD therapy as outlined to them pre-implant, but not issues around end-of-life care.7 What do Healthcare Professionals know and believe? A 2009 survey of over five hundred US based cardiologists, electrophysiologists, internists and geriatricians, presented with 5 end of life case vignettes, found significantly more would discuss a DNR, rather than ICD deactivation, in 4 out of five cases being 20-30% higher. Despite the 2010 guidance, a 2021 Canadian survey showed that 24% of nurses, 10% of fellows and 7% of cardiologists still believed shock deactivation was unethical.13 Predictors of such beliefs were sociocultural, including profession, region of training and spiritual beliefs. Despite clinicians stating that they would discuss ICD shock deactivation in certain circumstances, such as when signing a DNR, there is also an admission amongst noncardiology professionals that lack of knowledge can be a barrier.8 Other reasons quoted which result in clinicians rarely explicitly discussing ICD shock deactivation includes personal discomfort, lack of experience, time constraints and lack of guidance documentation.14 Given that 11% of the population over 50 years of age in Ireland suffer from two or more chronic diseases and many of our patients see different teams, and multiple members within the one team, as well as their own General Practitioner, the question of who should partake in discussions around ICD shock deactivation can be a difficult one. With potentially fragmented care, there can be a feeling that the responsibility lies elsewhere.8 In the UK, data would suggest that Cardiologists often focus on getting the patient better, and this perhaps results in the conversation not being had early enough. Cardiac Physiologists, who follow-up patients with devices, have opportunity to discuss but are reluctant because of lack of knowledge or confidence. In general terms, Heart Failure Nurses, feel they are already having those
