Clinician attitudes regarding ICD deactivation in DNR/DNI patients
BACKGROUND
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.
OBJECTIVE
To assess clinician opinions on managing ICDs in DNR/DNI patients and stratify it by specialty and training level.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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. Journal of Hospital Medicine 2017;12:498-502. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Implantable cardioverter-defibrillators (ICDs) offer lifesaving therapies to many patients and have been implanted in hundreds of thousands of patients.1 The population of patients with ICDs is growing rapidly, and the national ICD Registry reports over 12,000 devices are implanted monthly.2 This population includes patients with congenital heart disease, ischemic cardiomyopathy, and idiopathic arrhythmias. If these patients experience ventricular tachycardia or fibrillation, an ICD attempts to restore sinus rhythm and prevent death. While a shock from an ICD may be lifesaving, it can be a traumatic and startling experience for the patient and perhaps distressful for families to witness.3,4
Although ICDs are intended to save lives, they do not slow the progress of the patient’s underlying cardiac and noncardiac comorbidities. All these patients will eventually die, whether from their cardiac disease or another condition. The literature includes many anecdotes about patients shocked multiple times by their defibrillator while actively dying.4 These situations could be prevented with preemptive ICD deactivation. (ICDs can function not only as cardioverters and defibrillators, as implied by their name, but also as pacemakers. “Deactivation” as used in this paper refers only to disabling the tachycardia therapies. No distinction was made between defibrillation with a shock and anti-tachycardia pacing.) Therefore, research on ICD deactivation has emphasized patients who are acutely terminally ill, while less emphasis has been placed on patients who are not actively dying.4–8
Patients may, for a variety of reasons, request a do-not-resuscitate/do-not-intubate (DNR/DNI) order as their code status. However, it is not necessarily clear what a DNR/DNI order implies for ICD management. One survey of attending physicians found that 19% of respondents felt a DNR/DNI order was equivalent to requesting ICD deactivation.9 On the other hand, patients are split on whether they would want their device deactivated while in hospice or even at the very end of life.6 Heart Rhythm Society (HRS) guidelines favor a nuanced approach to ICD deactivation in DNR/DNI patients that emphasizes the individual patient’s comorbidities and goals.10 A patient’s individual circumstances might justify a choice to be DNR/DNI without deactivating the ICD. Decision-making in these circumstances requires a careful conversation between the patient and clinician. It is important to identify barriers that might prevent optimal shared decision-making.
Clinicians have been surveyed on ICD management at the end of life, but these studies have generally focused on attending physicians.5,9,11 However, physician trainees (ie, residents and fellows) as well as advanced practice providers (ie, physician assistants and nurse practitioners) are responsible for much of the clinical care provided to hospitalized patients. In particular, they are often the clinicians to discuss code status with patients. Different specialties (eg, cardiology, general medicine, and geriatrics) manage different sets of patients, which might affect clinicians’ opinions on ICD management. We therefore designed a survey to assess clinician attitudes and beliefs regarding ICD deactivation, including in non-terminally ill patients, and to evaluate for differences according to training level and specialty.
