Implantable cardioverter defibrillator devices: when, how and who should discuss deactivation with patients: a systematic literature review

Abstract

BackgroundImplantable cardioverter defibrillators (ICDs) are used to treat life-threatening cardiac arrhythmias and prevent sudden cardiac arrest. As recipients age they may develop greater risk of dying as a result of progressive multimorbidity rather than sudden cardiac death. Defibrillation shocks may prolong an uncomfortable dying process. Deactivation of the defibrillator would prevent this, yet is not always discussed and planned.AimTo systematically review published evidence on ICD deactivation discussions and make recommendations on when, how and who should facilitate effective and patient-centred deactivation discussions.MethodsUsing standard systematic review methods, MEDLINE, EMBASE, CINAHL and PsycInfo were searched for studies published in the English language between 2010 and March 2021. Inclusion criteria were studies of adults (≥18 years) and including discussions on ICD deactivation and/or related communication. Included studies were independently reviewed, data extracted, quality assessed and data synthesised using a deductive approach.ResultsOf the 8893 articles identified, 22 papers met the inclusion criteria. Deductive approach led to identification of five main themes: (1) timing of ICD deactivation discussions, (2) initiation of deactivation discussions, (3) advance directives, (4) barriers to discussions and (5) facilitators of discussions.ConclusionsDespite available guidelines, conversations on device deactivation are not being undertaken consistently. Evidence suggests lack of professional awareness of guidelines and limited training in communication skills. To prevent distress and promote comfortable dying, there needs to be a proactive clinical and policy initiative in the education of both professionals and patients and their relatives about device deactivation.

Aligning goals with care: Advance directives in older adults with implantable cardioverter‐defibrillators

“…Previous studies have reported that most patients with ICDs do not have advance directives, and when advance directives do exist, they rarely include specific instructions around the management of the ICD at the end of life. [7][8][9][10] The objective of this study was to quantify the prevalence of documented advance directives in individuals aged 80 and older with ICDs, with a focus on those with frailty and cognitive impairment.…”