SAN FRANCISCO – One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.
In addition, some physicians prefer further aggressive medical treatments and they postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley said in a poster presentation at the annual meeting of the Gerontological Society of America.
“People at the bedside caring for a dying patient … may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse [present].”
The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and “do not resuscitate” orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.
Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, noted Dr. Kelley and her associates. Overall, 21% expressed a preference for further medical treatments over deactivation of the ICD.
Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.
“I want [a patient or the family] to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked,” Dr. Kelley said.
Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. Most (58%) said guidance from experts about managing patients with ICDs would be helpful in their practices. There are no guidelines for managing the deactivation of ICDs.
The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.
Most Physicians Willing to Talk
In the following scenarios, the percentages indicate how many of the 558 surveyed physicians would discuss ICD deactivation, advance directives, or do not resuscitate (DNR) orders with patients.
▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:
ICD deactivation: 56%
Advance directives: 88%
DNR: 82%
▸ A man with advanced dementia who is agitated by medical appointments and tests:
ICD deactivation: 71%
Advance directives: 84%
DNR: 84%
▸ A woman with stage IV ovarian cancer who requests palliative care:
ICD deactivation: 79%
Advance directives: 94%
DNR: 93%
▸ A man with end-stage renal failure who declines dialysis:
ICD deactivation: 76%
Advance directives: 90%
DNR: 90%
▸ A woman with a massive stroke whose family has requested ventilator withdrawal:
ICD deactivation: 83%
Advance directives: 80%
DNR: 83%