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 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 reported in a poster presentation at the annual meeting of the Gerontological Society of America.
“People at the bedside caring for a dying patient—internists and palliative care physicians—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.”
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 (DNR) 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, reported Dr. Kelley and her associates. Overall, 21% of the commenters expressed a preference for further medical treatments (including medications, devices, and procedures) over ICD deactivation.
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.
“As a geriatrician and a primary care provider, if I'm ready to discuss other end-of-life topics with a patient or with the family, this would be on my list of things to discuss,” Dr. Kelley said. “I want them to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked.”
Data from a previous retrospective study that surveyed next of kin after a patient's death suggest that fewer than a fourth of ICDs get deactivated near the end of life, and then only after the patient suffered a painful shock from the device, she said.
Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. A majority (58%) said that guidance from experts regarding management of patients with ICDs would be helpful. 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.
In two of the patient vignettes, physicians who said they had no religious affiliation were more likely to discuss ICD deactivation with patients.
Most Physicians Willing to Talk
In the following scenarios, the percentages indicate how many of 558 surveyed physicians would discuss ICD deactivation, advance directives, or 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 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 requests ventilator withdrawal:
ICD deactivation: 83%
Advance directives: 80%
DNR: 83%