Abstract & Commentary
Are Implanted Defibrillator Therapies Deactivated at End of Life?
By Edward P. Gerstenfeld, MD
Professor of Medicine, Chief, Cardiac Electrophysiology, University of California, San Francisco
Dr. Gerstenfeld does research for Biosense Webster, Medtronic, and Rhythmia Medical.
Source: Kinch Westerdahl A, et al. Implantable cardioverter-defibrillator therapy before death: High risk for painful shocks at end of life. Circulation 2014;129:422-429.
This study aimed to determine the incidence of appropriate shocks, inappropriate shocks, and device malfunction prior to death in patients with implantable cardioverter-defibrillators (ICDs). The study was performed in Sweden where it is mandatory that all ICDs are explanted after death. The 26 participating pathology departments contributed 130 devices (5 nonfunctioning). Medical records were reviewed and autopsies and death certificates were obtained to determine the cause of death. ICDs were interrogated and electrograms from the 24 hours prior to death were retrieved and adjudicated by blinded investigators to determine whether shocks were appropriate. Death was classified as "sudden" if it occurred within 1 hour of symptoms. If true ventricular tachycardia/fibrillation (VT/VF) was present within 1 hour of death, the death was classified as arrhythmic. Electrical storm was defined as ≥ 3 shocks in the 24 hours prior to death. The majority of devices (82%) were implanted for secondary prevention and 35% were biventricular devices. At the time of death, 80% of patients were in a hospital or care facility. Although 52% of patients had do-not resuscitate (DNR) orders, ICD shock therapies remained active in half of these patients up to 1 hour before death. Twenty-five devices had been programmed off. There were 38 patients with VT/VF in the final 24 hours and 24 who had VT storm before death. A DNR order was present at the time of ICD shocks in 10 VT storm patients, and six of these patients received an average of 5.6 ± 6.5 shocks. Four patients received inappropriate shocks because of SVT or T wave oversensing. There were four deaths related to device malfunction, three due to undersensing of VF, and one due to a lead malfunction. The cause of death was determined to be sudden in 29 patients and arrhythmic in 16 (13%). The most common cause of death was congestive heart failure (37%). The authors concluded that most ICD patients died in the hospital and the devices remained active in more than half of the patients with a DNR order.
Commentary
ICD therapy can be lifesaving, and is now standard of care for patients with ischemic or nonischemic cardiomyopathy with reduced ejection fraction and for secondary prevention of ventricular tachycardia in patients with structural heart disease. After a decade of experience with ICDs, we now discuss both the benefits and risks of ICD placement with patients prior to implantation, including the risk of lead/device malfunction, and appropriate and inappropriate shocks. However, this study shows that we are often remiss in incorporating the ICD into end-of-life decisions with our patients. Although the presence of ICD shocks at the "end of life" is not surprising, it is striking that of 52 patients with DNR orders, ICD therapies remained on in half the patients. There are several reasons why these devices may not be deactivated. First, implanting electrophysiologists are often not involved in palliative or end-of-life care with their patients. Internists or family practitioners may not even know of an ICD being present, or consider it in their end-of-life planning. Finally, patients may not know of the option for deactivating the ICD at end of life.
What should we learn from this study? First, as implanting electrophysiologists and cardiologists, the ability to turn off the ICD should be discussed with the patient before or shortly after implantation. As difficult as the discussion is when considering life-saving therapy, a simple mention that the device can be turned off when no longer needed can actually be reassuring to patients. Patients should be encouraged to incorporate decisions regarding ICD therapy into living wills. Finally, internists, cardiologists, oncologists, and all those involved in end-of-life care should be educated to ask patients whether an ICD is present and if deactivation of shock therapies is appropriate. According to the Heart Rhythm Society consensus statement,1 electrophsyiologists should turn off device therapies when requested by a patient in the appropriate circumstance, or find a colleague to perform this action. Device representatives also have the ability to deactivate ICDs at remote sites, including patient homes, when ordered by an attending physician. ICDs have become an important tool in our fight against sudden death. However, this study reminds us that death is inevitable in all our patients. Deactivation of ICD therapies at end of life should be part of the commitment to our patients who have undergone ICD implantation.
REFERENCE
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Lampert R, et al. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 2010;7:1008-1026.
