Elsevier

American Heart Journal

Volume 157, Issue 4, April 2009, Pages 702-708.e1
American Heart Journal

Clinical Investigation
Outcomes, Health Policy, and Managed Care
Implantable cardioverter-defibrillator deactivation at the end of life: A physician survey

https://doi.org/10.1016/j.ahj.2008.12.011Get rights and content

Background

Among older adults, implantable cardioverter-defibrillator (ICD) use is increasing. ICD shocks can occur at end of life (EOL) and cause substantial distress, warranting consideration of ICD deactivation discussions. This nationwide physician survey sought to (1) determine if physicians discuss ICD deactivation at the EOL, (2) identify predictors of those discussions, and (3) ascertain physicians' knowledge/attitudes about ICD use.

Methods

We surveyed 4,876 physicians stratified by specialty (cardiologists, electrophysiologists, general internists, and geriatricians). The mailed survey presented 5 vignettes (eg, end-stage chronic obstructive pulmonary disease, advanced dementia) wherein ICD deactivation might be considered and 17 Likert-scaled items.

Results

Five hundred fifty-eight (12%) physicians returned surveys. Respondents were largely men (77%) and white (69%). Most physicians (56%-83%) said they would initiate deactivation discussions in all 5 vignettes, whereas significantly more (82%-94%) would discuss advance directives and do not resuscitate status. In logistic regression analyses, a history of prior deactivation discussions was an independent predictor of willingness to discuss deactivation (adjusted OR range, 2.8-8.8) in 4 of the 5 vignettes. General internists and geriatricians were less likely than electrophysiologists to agree that ICD shocks are painful and to distinguish between the ICD's pacing and defibrillator functions. Finally, most physicians believed that informed consent for ICD implantation should include information about deactivation (77%) and endorsed the need for expert guidance in this area (58%).

Conclusions

Most physicians would discuss ICD deactivation at EOL. The strongest predictor of this was a history of prior discussions. Knowledge about ICDs varies by specialty, and most expressed a desire for more expert guidance about ICD management at EOL.

Section snippets

Survey development

The survey included 5 clinical vignettes (see Appendix A) and 17 Likert-scaled items, along with items to elicit data on subjects' demographic and practice characteristics. Vignettes have been used extensively in social and biomedical research29, 30 and have been found to be particularly reliable as a measure of professional judgement.31, 32 The vignettes included in this survey were based on the clinical experience of the authors and depicted 5 patients with an ICD and a new terminal diagnosis

Results

Surveys were mailed to 4,876 physicians, 173 were returned as undeliverable and 558 (12%) physicians returned completed surveys. Respondents were predominantly white, male physicians who worked in private practices located in large northeastern cities (Table I). Most of the respondents devoted <50% of their practice to primary care and reported caring for >10 patients with ICDs, whereas almost half (48%) reported having had ≥6 discussions regarding ICD deactivation. Compared to nonrespondents,

Discussion

This study found that physicians report a substantially greater willingness to discuss advance directives and DNR with patients who have either terminal or progressive, incurable disease, as compared to ICD deactivation despite defibrillation being an integral part of resuscitation efforts. Decades of research and attention to end of life care, in addition to legislation such as the Patient Self-Determination Act, have promoted DNR and advance directives discussions as the “standard of care.”

Disclosures

Dr Kelley receives funding as a fellow in the AHRQ National Research Service Award program at the University of California Los Angeles. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.

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