Implantable Cardioverter Defibrillator Deactivation Research Articles

Patient and Professional Factors That Impact the Perceived Likelihood and Confidence of Healthcare Professionals to Discuss Implantable Cardioverter Defibrillator Deactivation in Advanced Heart Failure: Results From an International Factorial Survey.

Rate of implantable cardioverter defibrillator (ICD) implantations is increasing in patients with advanced heart failure. Despite clear guideline recommendations, discussions addressing deactivation occur infrequently. The aim of this article is to explore patient and professional factors that impact perceived likelihood and confidence of healthcare professionals to discuss ICD deactivation. Between 2015 and 2016, an international sample of 262 healthcare professionals (65% nursing, 24% medical) completed an online factorial survey, encompassing a demographic questionnaire and clinical vignettes. Each vignette had 9 randomly manipulated and embedded patient-related factors, considered as independent variables, providing 1572 unique vignettes for analysis. These factors were determined through synthesis of a systematic literature review, a retrospective case note review, and a qualitative exploratory study. Results showed that most healthcare professionals agreed that deactivation discussions should be initiated by a cardiologist (95%, n = 255) or a specialist nurse (81%, n = 215). In terms of experience, 84% of cardiologists (n = 53) but only 30% of nurses (n = 50) had previously been involved in a deactivation decision. Healthcare professionals valued patient involvement in deactivation decisions; however, only 50% (n = 130) actively involved family members. Five of 9 clinical factors were associated with an increased likelihood to discuss deactivation including advanced age, severe heart failure, presence of malignancy, receipt of multiple ICD shocks, and more than 3 hospital admissions during the previous year. Furthermore, nationality and discipline significantly influenced likelihood and confidence in decision making. Guidelines recommend that healthcare professionals discuss ICD deactivation; however, practice is suboptimal with multifactorial factors impacting on decision making. The role and responsibility of nurses in discussing deactivation require clarity and improvement.

Deactivation of Implantable Cardioverter-Defibrillators in Heart Failure: A Systematic Review.

Implantable cardioverter-defibrillator aids in the prevention of cardiac arrest by delivering an electrical shock in the presence of life-threatening ventricular arrhythmias. Although implantable cardioverter-defibrillators are essential to sustain life in patients with end-stage heart failure, it is important to consider the option for prompt deactivation of implantable cardioverter-defibrillators to prevent inappropriate electrical shocks at the end of life where death is inevitable. In this systematic review, available literature was reviewed, using six electronic databases, to identify problems that may delay the deactivation of implantable cardioverter-defibrillators and address possible considerations for implantable cardioverter-defibrillator management to improve end-of-life care. Studies reported low occurrence of deactivation discussions, lack of knowledge regarding implantable cardioverter-defibrillator deactivation among most patients, and provider's perception of being unqualified to initiate discussion and perform deactivation of implantable cardioverter-defibrillator. A need for additional patient and provider education and periodic discussions between patient and provider on implantable cardioverter-defibrillator deactivation should occur, as well as development of protocol or policy to guide care at the end of life.

PP04 Co-Constructing Recommendations With Patients And Health Professionals

Introduction:Decision-making about replacement or modification of an implantable cardioverter defibrillator (ICD) must be patient-centered and clinically appropriate. We engaged both patients and health care professionals in a multi-method approach in order to recommend structures and processes that facilitate informed and shared decision-making.Methods:A systematic literature review (2000 to 2017) was performed focusing on the patient's perspective and the optimal organization of structures and processes for decision-making. A province-wide field evaluation based on medical chart review was carried out to provide ‘real world’ evidence in Québec's six ICD implanting centers (1 July to 31 December, 2016; N = 418). Patients and health care professionals reviewed the findings of the review and field evaluation, and deliberated recommendations in an anonymous manner by electronic mail. A joint meeting focused on proposed recommendations concerning shared decision-making.Results:The patients provided feedback on the literature review based on their ICD experience, and highlighted the need for better and more interactive decision aids, clinical information and time, and a private space for sensitive discussions. The field evaluation underlined the variability of treatment choices at the time of replacement and that more than one in ten patients had undergone ICD deactivation. Proposed recommendations focus on multi-disciplinary, integrated follow-up of patients and outline best practice for incorporating patient wishes and life objectives when discussing treatment options. The multi-round consultation process allowed both patients and professionals to co-construct recommendations with our evaluation team.Conclusions:This multi-method approach enriched our interpretation of literature and ‘real world’ data and facilitated identification and prioritization of important themes. Partnership with both patients and clinicians added a new and energizing dynamic to our evaluation and recommendation processes. We acknowledge the contribution of the members of the patient committee and the clinical experts committee.

Moral Distress at the End of a Life: When Family and Clinicians Do Not Agree on Implantable Cardioverter-Defibrillator Deactivation

A 63-year-old man with end-stage ischemic cardiomyopathy presented with incessant ventricular tachycardia. He had been hospitalized multiple times in the past year for severe heart failure. As he approached end of life and was regularly receiving defibrillator shocks, his care team recommended deactivation of his implantable cardioverter-defibrillator. However, his family did not wish to allow deactivation, reporting a religious obligation to prolong his life, regardless of the risk of suffering. The patient was unable to adequately participate in the decision-making process. An implantable cardioverter-defibrillator can serve to avoid sudden death but may lead to a prolonged death from heart failure. This possibility forces the examination of values regarding prolongation of life, sometimes producing disagreement among stakeholders. Although ethical consensus holds that defibrillator deactivation is legal and ethical, disagreements about life prolongation may complicate decision making. The ethical, technical, and medical complexity involved in this case speaks to the need for clear, prospective communication involving the patient, the patient's family, and members of the care team.

P2983Who decides what and when: a holistic understanding of decision-making in implantable cardioverter defibrillator deactivation

Background: Implantable Cardioverter Defibrillators (ICDs) are cornerstone in the treatment of sudden cardiac death. Empirical studies have found many patients with an ICD are unaware of the potential for device deactivation, limiting shared decision-making. Dying patients with an active ICD have an increased risk of experiencing painful futile shocks.Purpose: Case study approach to explore patients', carers' and professionals' perspectives of ICD deactivationMethods: A purposive sample of ten case studies was selected that fulfilled the eligibility criteria defined by the research team. A “case” referred to a patient, their carer and two clinical team members. Suitable patients were identified by their clinician with carers nominated by respective patients. Informed consent was obtained before data was collected sequentially through semi-structured interviews with patients and carers, focus groups with clinical team members and patients' medical records. Interviews and focus groups were digitally recorded and transcribed verbatim. Framework analysis was used.Results: Data from in-depth interviews (n=20), focus groups (n=9) and medical records (n=10). Four key themes developed which included-• Limited communication pre-implantation: Patients were uninformed about deactivation before device implantation. Professionals in Focus Group 6 believed they acted “in the patients' best interests”, unaware their omission of information was contrary to recommended guidelines.• Restricted Knowledge: Patients' and carers lacked knowledge on the device and severity of illness. Patient 2 said “I don't think it had to be turned off, no one ever said to me”. In a number of the cases, this led to a breakdown in their therapeutic relationship.• ICD perceived as a life saver: Despite dire heart failure symptoms, patients maintained an idealistic attitude towards the future role of the ICD. Terms included “peace of mind” (patient 2), “protected” (patient 3) and “an insurance if I need it” (patient 5). Professionals were reluctant to dispel optimism, underestimating the impact patients' and carers' misunderstandings had on shared decision-making.• Patients' choices and decisions limited: Patients believed the decision to deactivate their ICD resided with their clinician. Patient 3 noted “no-one has the right to make that decision unless medically trained”. Professionals believed that unless the patient was incapable, the decision of deactivation was the patient's. Advanced planning was absent in all of ten case studies.Conclusion: Patient and carer involvement in end-of-life decision-making is hampered by a lack of knowledge on the ICD and prognosis. Professionals' decision to embark on a discussion concerning deactivation was idiosyncratic and often based on experiential knowledge rather than guideline recommendations. Frequently these discussions occurred when death was imminent, leaving minimal time for the patient and carer to make preparations.Acknowledgement/Funding: Supported by Public Health Agency, HSC Research and Development division. Awarded HFA Nurse Fellowship grant 2014

1256Family involvement in decisions concerning implantable cardioverter defibrillators: results from an international survey

Background: European and International expert guidelines recommend patients' with an Implantable Cardioverter Defibrillator (ICD) and their families are informed about deactivation. Recent empirical studies demonstrate diverse professional opinion regarding the involvement of family in the discussion about deactivation to dying patients.Purpose: To determine the impact of family involvement on healthcare professionals' decision to discuss ICD deactivation.Methods: Data from a systematic review, retrospective case note review and ten case studies identified social support as an important factor or Independent Variable (IV). The IV was classified into three levels, before being randomly assigned within vignettes of a factorial survey. The anonymised survey consisted of six vignettes, a demographic questionnaire and an opportunity for participants to record their most “recent case”. The survey was distributed electronically through a secure IT platform to healthcare professionals across Europe and America. Analysis included descriptive statistics, in addition to Multiple Regression and ANOVA to identify correlations between social support as an IV and two dependent variables. Thematic analysis was conducted on the qualitative data obtained from “recent cases”.Results: A total of 1614 vignettes were completed by 269 professionals (168 nurses, 64 clinicians, 37 allied health professionals), mean age 46 years (range 26–65 years) with majority from Europe (n=217, 81%). Social support did not impact the likelihood of professionals' to discuss ICD deactivation (p=0.740). However, professionals who managed patients living with a family member who shared healthcare decisions with them, were significantly more confident (p=0.014) in discussing deactivation, compared to professionals caring for patients with no family support. Almost half of participants (N=35; 44%) who provided a recent case documented family involvement. This ranged from a supportive shared role “wife was terrified of seeing her husband shocked on his deathbed, contributing to a decision” (Healthcare Professional 1) to that of a surrogate decision-maker “family made the decision to deactivate the ICD as death was clos” (Healthcare Professional 2).Conclusions: Family members can play an important role in the decision whether to deactivate an ICD, however this is contingent on their knowledge and previous involvement. Professionals should ensure families are involved in discussions and encourage shared decision-making. Further research is needed into the interventions required to support family members, ultimately improving end-of- life care for patients with an ICD.Acknowledgement/Funding: Work Supported by Public Health Agency, HSC Research and Development division. Awarded HFA Nurse Fellowship grant 2014

Implantable cardioverter defibrillator knowledge and end-of-life device deactivation: A cross-sectional survey

Background: End-of-life implantable cardioverter defibrillator deactivation discussions should commence before device implantation and be ongoing, yet many implantable cardioverter defibrillators remain active in patients’ last days. Aim: To examine associations among implantable cardioverter defibrillator knowledge, patient characteristics and attitudes to implantable cardioverter defibrillator deactivation. Design: Cross-sectional survey using the Experiences, Attitudes and Knowledge of End-of-Life Issues in Implantable Cardioverter Defibrillator Patients Questionnaire. Participants were classified as insufficient or sufficient implantable cardioverter defibrillator knowledge and the two groups were compared. Setting/participants: Implantable cardioverter defibrillator recipients (n = 270, mean age 61 ± 14 years; 73% male) were recruited from cardiology and implantable cardioverter defibrillator clinics attached to two tertiary hospitals in Melbourne, Australia, and two in Kentucky, the United States. Results: Participants with insufficient implantable cardioverter defibrillator knowledge (n = 77, 29%) were significantly older (mean age 66 vs 60 years, p = 0.001), less likely to be Caucasian (77% vs 87%, p = 0.047), less likely to have received implantable cardioverter defibrillator shocks (26% vs 40%, p = 0.031), and more likely to have indications of mild cognitive impairment (Montreal Cognitive Assessment score <24: 44% vs 16%, p < 0.001). Insufficient implantable cardioverter defibrillator knowledge was associated with attitudes suggesting unwillingness to discuss implantable cardioverter defibrillator deactivation, even during the last days towards end of life (p < 0.05). Conclusion: Implantable cardioverter defibrillator recipients, especially those who are older or have mild cognitive impairment, often have limited knowledge about implantable cardioverter defibrillator deactivation. This study identified several potential teachable moments throughout the patients’ treatment trajectory. An interdisciplinary approach is required to ensure that discussions about implantable cardioverter defibrillator deactivation issues are initiated at appropriate time points, with family members ideally also included.

Clinician Attitudes Regarding ICD Deactivation in DNR/DNI Patients.

Implantable cardioverter-defibrillators (ICDs) offer lifesaving therapies but can become burdensome at the end of life. Many ICD patients choose to implement a do-not-resuscitate/do-not-intubate (DNR/DNI) order. When hospitalized, patients are seen by a range of clinicians whose beliefs about ICD management in DNR/DNI patients may vary. To assess clinician opinions on managing ICDs in DNR/DNI patients and stratify it by specialty and training level. An online survey was sent to attending physicians, fellows, advanced practice providers (physician assistants and nurse practitioners), and residents in general internal medicine, cardiology, electrophysiology, and geriatrics at an academic medical center. Residents were compared to attending physicians, and attending physicians were additionally stratified by specialty. The response rate was 32%, yielding 161 complete responses. Among residents (n = 73), 49.3% were comfortable with discussing ICD deactivation and 16.4% asked about it routinely. By contrast, among attending physicians (n = 66), 78.8% were comfortable with discussing deactivation and 34.8% routinely asked. Fewer general internists (19.2% of inpatient internists, 10.5% of outpatient internists) routinely asked about ICD deactivation as compared with 83.3% of geriatricians and 73.3% of cardiologists/electrophysiologists. Twenty-one percent of all respondents felt a DNR/DNI order equated to requesting ICD deactivation; Heart Rhythm Society (HRS) guidelines favor a more nuanced approach. Residents are less comfortable discussing ICD deactivation than attending physicians and do so less frequently. General internists discuss deactivation less routinely than cardiologists and geriatricians. Many providers hold opinions about ICD deactivation that differ from HRS guidelines. Additional didactic education could help close these gaps in clinician practice.

Implantable cardioverter-defibrillator deactivation at the end of life: ethical, clinical and communication issues

The number of cardioverter-defibrillator implants is increasing worldwide, with the main indication being primary prevention of sudden cardiac death. During the follow-up, patients may die from progression of their underlying heart disease or from nonarrhythmic causes, such as malignancies, dementia and lung disease, without receiving appropriate shocks until the last few days or weeks of their life. These events occur roughly in 30% of patients, mainly in the last 24 hours before death. In this case, inappropriate and even appropriate shock deliveries can no longer prolong life and may simply lead to pain and reduced quality of life. Therefore, it appears important to discuss early with the patients and their relatives about deactivation of the implantable cardioverter-defibrillator (ICD) at the end of life.The goal of this review is to provide an overview of the ethical, clinical and communication issues of ICD deactivation, with a special focus on patients' wishes. It is outlined that patients are not adequately informed about risks and benefits of ICD and the option of ICD deactivation; the doctors are not used to discuss with the patients the topics of end-of-life decisions. Complete information must be part of current informed consent before ICD implantation and should be updated during the follow-up, with special attention to patients with heart failure in relation to their prognosis and advance directives, as suggested by international guidelines.

The ethics of unilateral implantable cardioverter defibrillators and cardiac resynchronization therapy with defibrillator deactivation: patient perspectives.

Decisions about deactivation of implantable cardioverter defibrillators (ICDs) are complicated. Unilateral do-not-resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. Unilateral deactivation of ICDs may be seen as a logical extension of a unilateral DNR order. However, the ethical implications of unilateral ICD deactivation have not been explored. Sixty patients who had an ICD or cardiac resynchronization therapy with defibrillator (CRT-D) were interviewed at a quaternary medical centre outpatient electrophysiology practice. Survey questions addressed whether deactivation of defibrillator function was included in advanced directives, whether deactivation constitutes physician-assisted suicide, and whether unilateral deactivation can be ethically justified. Responses were elicited to scenarios in which defibrillation function was deactivated in different contexts (including patient request to deactivate, existing DNR, and unilateral deactivation). Only 15% of respondents had thought about device deactivation if they were to develop a serious illness from which they were not expected to recover. A majority (53%) had advance directives, but only one mentioned what to do with the device. However, a majority (78%) did not consider deactivation of an ICD shocking function against patients' wishes to be ethical or moral. Management of ICDs and CRT-Ds as patients near the end of their lives creates ethical dilemmas. Few patients consider device deactivation at end-of-life, although a large majority believes that unilateral deactivation is not ethical/moral, even in the setting of medical futility. Advance care planning for these patients should address device deactivation.

Planning for Deactivation of Implantable Cardioverter Defibrillators at the End of Life in Patients With Heart Failure.

Implantable cardioverter defibrillators (ICDs) may be burdensome in end-stage heart failure. At the end of life, as many as one-fifth to one-third of patients experience an ICD shock. Critical care nurses should be aware of the potential burden of these shocks at the end of life as well as the ethics and organizational policies surrounding ICD deactivation. This literature review examines the issues surrounding ICD therapy at the end of life. Based on this author's findings, recommendations for discussing and implementing ICD deactivation are offered. Health care organizations should have clear policies addressing ICD deactivation to provide for seamless integration of palliative care services throughout the course of heart failure. These policies should empower nurses to activate resources in a timely manner and should clearly outline processes for ICD deactivation.

Ventricular arrhythmias and sudden cardiac death

### Key points There are 50–100 unexpected, sudden cardiac deaths (SCDs) per 100 000 population per year in Europe and USA, categorized by symptom onset to cardiac arrest time of <1 h.1 Despite the decline in coronary artery disease mortality and advancements in resuscitation services, survival from these events remains low. Unfortunately, they often occur outside the hospital environment and are associated with a survival rate of <10%. The majority occur in adults over 35 yr of age and at least half of these events can be attributed to ventricular arrhythmias, although the true incidence is unknown due to inevitable degeneration to asystole if unwitnessed. These arrhythmias may be the presenting complaint in the emergency department and may feature throughout the perioperative period, including at preoperative assessment, during surgery and in the recovery phase, for example in intensive care. They may also be the direct target of therapy in the case of electrophysiological catheter ablation and implantable cardioverter defibrillators (ICDs). They are more frequent and carry greater risks in patients with structural heart disease, but younger patients with ion-channel abnormalities can also be susceptible.2 This review classifies the causes and significance of ventricular arrhythmias based on the presence or absence of structural heart disease and provides a simple system to aid confident distinction from supraventricular arrhythmias. …

End-of-life care in a cardiology department: have we improved?

BackgroundEnd-of-life care is not usually a priority in cardiology departments. We sought to evaluate the changes in end-of-life care after the introduction of a do-not-resuscitate (DNR) order protocol.Methods & ResultsRetrospective analysis of all deaths in a cardiology department in two periods, before and after the introduction of the protocol. Comparison of demographic characteristics, use of DNR orders, and end-of-life care issues between both periods, according to the presence in the second period of the new DNR sheet (Group A), a conventional DNR order (Group B) or the absence of any DNR order (Group C). The number of deaths was similar in both periods (n = 198 vs. n = 197). The rate of patients dying with a DNR order increased significantly (57.1% vs. 68.5%; P = 0.02). Only 4% of patients in both periods were aware of the decision taken about cardiopulmonary resuscitation. Patients in Group A received the DNR order one day earlier, and 24.5% received it within the first 24 h of admission (vs. 2.6% in the first period; P < 0.001). All patients in Group A with an implantable cardioverter defibrillator (ICD) had shock therapies deactivated (vs. 25.0% in the first period; P = 0.02).ConclusionsThe introduction of a DNR order protocol may improve end-of-life care in cardiac patients by increasing the use and shortening the time of registration of DNR orders. It may also contribute to increase ICD deactivation in patients with these orders in place. However, the introduction of the sheet in late stages of the disease failed to improve patient participation.

Increased Incidence of VentricularArrhythmias in Patients WithAdvancedCancer and ImplantableCardioverter-Defibrillators.

This study evaluated the incidence of ventricular arrhythmia and implantable cardioverter-defibrillator (ICD) therapies in patients with a diagnosisof cancer. Cardiac disease and cancer are prevalent conditions and share common predisposing factors. Nostudies have assessed the impact of cancer on the burden of ventricular arrhythmia in patients with cancer andICDs. Retrospective study of patients with an ICD and cancer who were followed from January 2007 to June 2015. Rates of ventricular tachycardia (VT) and ventricular fibrillation (VF) before and after patients' cancers were diagnosed were evaluated by searching device data collection systems. Rates were adjusted for length of follow-up and compared using the Wilcoxon test, and times to first therapy following diagnosis (stages I to III vs. IV) were compared using Kaplan-Meier curves and log-rank test. Among 1,598 patients with an ICD, 209 patients (13.1%) had a pathological diagnosis of malignancy; and in 102 patients (6.4%), malignancy was diagnosed following device insertion. After the diagnosis of cancer, 32% of patients experienced VT/VF over 23.2 ± 23.6 months, and the frequency of arrhythmic events was significantly increased after the diagnosis (1.19 ± 0.32 vs. 0.12 ± 0.21 episodes per month, respectively; p= 0.03). The incidence of VT/VF was markedly higher in patients with stage IV cancer than in those with earlier stages (p= 0.03). In this group, the incidence of VT/VF was 41.2%, with an average of 7.2 ± 18.5 events per patient, all of whom received ICD shocks. The rate of ICD deactivation in stage IV patients was 35.3%. Inappropriate therapies occurred in 13.7%, and atrial fibrillation was themost frequent cause. One-third of patients who had received ICDs developed ventricular arrhythmia after a diagnosis of cancer. The incidence was significantly higher in those with advanced metastatic disease. Findings underscore the need to discuss ICD management as part of end-of-life care.

Decision-Making of Patients With Implantable Cardioverter-Defibrillators at End of Life: Family Members' Experiences.

Many patients with advanced heart failure (HF) experience the life-extending benefits of implantable cardioverter-defibrillators (ICD), but at the end stage of HF, patients may experience shocks with increasing frequency and change the plan for end-of-life (EOL) care including the deactivation of the ICD. This report describes family members' experiences of patients with ICD making decisions at EOL. Understanding the decision-making of patients with ICD at EOL can promote informed decision-making and improve the quality of EOL care. This pilot study used a mixed methods approach to test the effects of a nurse-guided discussion in decision-making about ICD deactivation (turning off the defibrillation function) at the EOL. Interviews were conducted, audiotaped, and transcribed in 2012 to 2013 with 6 family members of patients with advanced HF and ICDs. Three researchers coded the data and identified themes in 2014. Three main themes described family members' experiences related to patients having HF with ICDs making health-care decision at EOL: decision-making preferences, patients' perception on ICD deactivation, and communication methods. Health-care providers need to have knowledge of patients' decision-making preferences. Preferences for decision-making include the allowing of appropriate people to involve and encourages direct conversation with family members even when advance directives is completed. Information of ICD function and the option of deactivation need to be clearly delivered to patients and family members. Education and guidelines will facilitate the communication of the preferences of EOL care.

Patient perceptions of implantable cardioverter-defibrillator deactivation discussions: A qualitative study.

Background:There is a class I recommendation for implantable cardioverter-defibrillator deactivation discussions to occur between physicians and heart failure patients. Few studies have reported the patient’s perspective on the timing of implantable cardioverter-defibrillator deactivation discussions.Aim:To determine patient awareness, preferences and timing of implantable cardioverter-defibrillator deactivation discussions.Design:Grounded theory was used to collect and analyze interview data from 25 heart failure patients with an implantable cardioverter-defibrillator.Setting and participants:Patients with an implantable cardioverter-defibrillator, from the Heart Function Clinic at University Health Network (Toronto, Canada).Results:The sample (n = 25) was predominately male (76%) with an average age of 62 years. Patients identified three stages where they felt implantable cardioverter-defibrillator deactivation should be discussed: (1) prior to implantation, (2) with any significant deterioration but while they were of sound mind to engage in and communicate their preferences and (3) at end of life, where patients wished further review of their previously established preferences and decisions about implantable cardioverter-defibrillator deactivation. Most patients (n = 17, 68%) said they would consider deactivation, six (24%) were undecided and two (8%) were adamant they would never turn it off.Conclusion:The patient preferences identified in this study support the need to include information on implantable cardioverter-defibrillator deactivation at implant, with change in clinical status and within broader discussions about end-of-life treatment preferences. Using this process to help patients determine and communicate their implantable cardioverter-defibrillator deactivation preferences may reduce the number of patients experiencing distressing implantable cardioverter-defibrillator shocks at end of life.

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

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.

Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners.

Unilateral do-not-resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. We investigated whether electrophysiology practitioners believe medical futility justifies unilateral implantable cardioverter defibrillator (ICD) deactivation. Email invitations to take an online survey were sent to 1,894 electrophysiology practitioners. A total of 384 responses were collected (response rate 20.6%). Though the sample included respondents from Europe, Asia, Australia, South America, and Africa, the majority were from North America (78%), were academically affiliated (64%), and practiced in an urban setting (67.8%). Deactivation of ICD shock function in agreement with patient wishes and a preexisting DNR were not considered physician-assisted suicide (93.2%, 358/384). However, a majority of the sample responded that it was not ethical/moral for doctors to deactivate ICDs against patients' wishes (77.1%, 296/384) or against family/surrogates' wishes (72.4%, 278/384), even in the context of medical futility. A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding cardiopulmonary resuscitation or external defibrillation in a code (72.7%, 277/381), but was different than deactivating pacing in a pacemaker-dependent patient (82.8%, 318/384). In the classification of interventions, a plurality (43.0%, 165/383) regarded ICDs to be unlike any other intervention. Concerning pacemakers, 50% (191/382) considered them to be like dialysis (a therapy that keeps patients alive). This international sample of electrophysiology practitioners considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not.

Abstract 9923: The Ethics of Unilateral ICD and CRT-D Deactivation: Patient Perspectives

Background: Decisions about deactivation of implantable cardioverter defibrillators (ICDs) are complicated. Unilateral Do-Not-Resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. Unilateral deactivation of ICDs may be seen as a logical extension of a unilateral DNR order. Methods: 60 respondents who had an ICD or cardiac resynchronization therapy ICD (CRT-D) were interviewed at a quaternary medical center outpatient electrophysiology practice. Survey questions addressed the inclusion of ICD deactivation in advanced directives, whether ICD deactivation constitutes physician-assisted suicide, and whether unilateral ICD deactivation can be ethically justified. The average age was 59 (range 23-89), and 70% were male. Of the respondents, 35% had ICDs, and 65% had CRT-Ds. Respondents had had their devices for an average of 6.74 years (range 0.11-25). 82% of respondents were Caucasian, 15% were African American and 3% were Hispanic. Results: Only 15% of patients had thought about device deactivation if they were to develop a serious illness from which they were not expected to recover, and single respondents were more likely to have considered this point (38%, p=0.03). A small majority (53%) had advance directives, and only one mentioned what to do with the device. Only 3% had discussed device management with clinicians. Most (55%) believed turning off a patient’s pacemaker was no different than not performing CPR or administering external defibrillation. A majority (77%) did not consider device deactivation in accordance with patient wishes to be physician-assisted suicide. A majority (78%) responded that it was not ethical/moral for doctors to deactivate ICDs against patients’ wishes. Conclusion: In an era of cost-consciousness and scrutiny of resources, management of ICDs and CRT-Ds as patients near the end of their lives create ethical dilemmas. Few patients consider device deactivation at end of life, though a large majority believes that unilateral deactivation is not ethical or moral, even in the setting of medical futility. Advance care planning for these patients should address device deactivation.

A Study to Improve Communication Between Clinicians and Patients With Advanced Heart Failure: Methods and Challenges Behind the Working to Improve Discussions About Defibrillator Management Trial

We report the challenges of the Working to Improve Discussions About Defibrillator Management trial, our novel, multicenter trial aimed at improving communication between cardiology clinicians and their patients with advanced heart failure (HF) who have implantable cardioverter defibrillators (ICDs). The study objectives are (1) to increase ICD deactivation conversations, (2) to increase the number of ICDs deactivated, and (3) to improve psychological outcomes in bereaved caregivers. The unit of randomization is the hospital, the intervention is aimed at HF clinicians, and the patient and caregiver are the units of analysis. Three hospitals were randomized to usual care and three to intervention. The intervention consists of an interactive educational session, clinician reminders, and individualized feedback. We enroll patients with advanced HF and their caregivers, and then we regularly survey them to evaluate whether the intervention has improved communication between them and their HF providers. We encountered three implementation barriers. First, there were institutional review board concerns at two sites because of the palliative nature of the study. Second, we had difficulty in creating entry criteria that accurately identified an HF population at high risk of dying. Third, we had to adapt our entry criteria to the changing landscape of ventricular assist devices and cardiac transplant eligibility. Here we present our novel solutions to the difficulties we encountered. Our work has the ability to enhance conduct of future studies focusing on improving care for patients with advanced illness.