70 Implantable Cardioverter Defibrillator Deactivation in End of Life Care: Retrospective Analysis of Deactivation Trends from 2011–2014

Abstract

Background Implantable Cardioverter Defibrillators (ICDs) improve survival from life threatening arrhythmias. If a patient requires end of life care it is questionable whether life-sustaining treatments such as defibrillation are appropriate. Several studies have demonstrated that deactivation (switching off) of the ICD is rarely considered even when a DNR is in place. This can result in patients dying with an active ICD possibly receiving shocks in the last days or hours of life. Health care professionals lack of understanding in regards ICD deactivation is a major challenge. Method ICD deactivation trends (2011 – 2014) were analysed retrospectively following the introduction of a health care professional ICD deactivation awareness campaign and simplified referral process. This also included routine discussion of ICD deactivation with patients and relatives pre-implantation and 1 month follow up. An education DVD for health care professionals explaining the importance of ICD deactivation was introduced along with a standardised ICD deactivation request form as advocated in the All-Wales ICD deactivation guidance. The ICD deactivation DVD was piloted for accuracy and clarity. Results Between 2011 – 2014 annual ICD deactivation rates increased (Figure 1). The majority were performed in the hospital setting (20) with only 6 being deactivated in the patients home (Figure 2). Most deactivations were requested by physicians, heart failure specialist nurses and general practitioners respectively. Medical reasons for deactivation included heart failure, cancer or dementia. The time from receiving a request for deactivation to actual deactivation was approximately 2 working days with 9 patients receiving temporary deactivation with the use of an external magnet. The period from deactivation to death varied considerably from 8 h to 18 months. 2 patients condition improved and their ICDs were re-activated (switched on). Conclusion The introduction of a standardised approach to discussing ICD deactivation pre-implantation and 1 month follow–up, the use of a deactivation request form and the awareness campaign resulted in an increase in deactivations. This service improvement could be replicated nationally as it is a fundamental aspect of patient safety and dignity in end of life care.