Improving rates of implantable cardioverter defibrillator deactivation in end-of-life care

Abstract

Implantable cardioverter defibrillators (ICDs) save lives in selected patients at risk of sudden cardiac death. However, in patents suffering with terminal illness, ICD therapy could pose a risk of unnecessary futile shocks which could lead to undignified discomfort in their final days of life. National guidelines advise that patients approaching the end of their natural life should be offered a compassionate choice of having their defibrillator deactivated. Following an actual clinical incident involving a patient receiving avoidable ICD shocks in his final hours, we identified shortcomings in communication and gaps in knowledge about ICD management in end-of-life care. We developed a quality improvement programme targeting training and educational support to general physicians and nurses at our large District General Hospital. A series of interventions were delivered including Grand Round presentation, departmental seminars and publicity posters. In parallel, we introduced a local protocol for implementing ICD deactivation which was published on our intranet for Trust-wide accessibility. Following interventions, we examined the clinical notes of each end-of-life care patient who died with an ICD in situ over a 6-month observation period and recorded the proportion who received consent-guided ICD deactivation versus died with an active ICD in situ because no deactivation discussion had been offered. Before our interventions in 2015, 0 out of 10 eligible patients (0%) received consent-guided ICD deactivation. Six months into our campaign to encourage healthcare workers to undertake advance care planning discussion in 2016, 7 out of 13 eligible patients (54%) received consent-guided ICD deactivation and no patients received shocks in their final month of life. This programme was successful in raising awareness of this emerging issue, improving physician knowledge and delivering patient choice as well as contributing to safe and compassionate end-of-life care.

Unmet device reprogramming needs at the end of life among patients with implantable cardioverter defibrillator: A systematic review and meta-analysis

“…Among the three studies that could not be included in the meta-analysis, one assessed the effectiveness of an institutional education campaign about device reprogramming at the end of life and showed that, after the campaign, out of the 13 patients who died, seven had the device reprogrammed. 27 The remaining two studies had a sample size of less than 15 patients for the analysis, due to missing data or because, being a prospective study, most of the patients were still alive. 20 , 25 …”

“…Similarly, institutional studies assessing the effectiveness of an intervention in a short period are not adequate as the sample size tends to be very small and the reported estimate would correspond to a specific intervention rather than a prevalence derived from routine clinical practice. 27 The main strength of our study is that ours was the first to summarize and critically assess the prevalence of the implantable cardioverter defibrillator reprogramming at the end of life. On the other hand, without claiming to demonstrate or infer causality, the study showed an improvement in the prevalence of the device reprogramming at the end of life after the publication of the HRS and the EHRA statements in 2010.…”

Improving implantable cardioverter defibrillator deactivation discussions in admitted patients made DNR and comfort care

“…A related project by Javaid et al used teaching sessions to increase the rate of ICD deactivation from 0% to 54% over 6 months 11. No patients received shocks during their study as well.…”

Implantable cardioverter defibrillators at the end of life: future perspectives on clinical practice

“…A recent UK study by Javaid and colleagues reported on an easy-to-implement but effective programme to improve the attention given to ICD deactivation [ 29 ]. This programme encompassed: (1) raising awareness and increasing knowledge about ICD deactivation by presenting research and guidelines to different medical departments; (2) e-mailing all staff who were not able to be present during these presentations; (3) developing and distributing informative posters about the ICD and end-of-life care on medical wards; and (4) offering teaching and checklists to staff working on medical wards.…”