Implantable Cardioverter Defibrillator Management at the End of Life

Stopping Superfluous Shocks With System Solutions

“…You had every intention of remembering, but the circumstances of your otherwise busy life caused you to forget. It appears this may have been what happened in the Teachable Moment by Kelly et al in this issue of JAMA Internal Medicine . While there has been much written about barriers to deactivating implantable cardioverter defibrillators (ICDs), most clinicians would agree that an 87-year-old man with incurable metastatic cancer in sepsis with a previously stated wish to not be resuscitated should have his ICD deactivated.…”

“…Cardiac resynchronization defibrillators can substantially improve patient symptoms from resynchronization of cardiac systole. In contrast, ICDs, such as that implanted for the patient in the Teachable Moment presented, do not affect patient symptoms, nor are ICDs associated with heart failure status or burden of ventricular arrhythmias.…”

“…Applicable to the patient presented in the Teachable Moment, there are many opportunities for the health care system (including clinicians, health care staff, nurses, and patient advocates) to explore and react to the changing wishes of patients regarding resuscitation. The first opportunity occurs at the time of the initial implant when patients should be informed about the capability to deactivate ICD shocks, if desired or required, in the future.…”

“…Second, a review of future goals and resuscitation preferences could occur before the time of ICD generator or battery change. Third, the time of receiving a diagnosis of incurable illness (such as metastatic kidney cell cancer as for the patient presented in the article) is an ideal time to readdress goals of care. Finally, the many subsequent prognostic discussions, during hospitalization(s), or palliative care consultation (either inpatient or outpatient) all provide occasions to address, review, and confirm resuscitation preferences.…”