Implantable cardioverter-defibrillator deactivation at the end of life: A physician survey

Abstract

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. 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. 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%). 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.