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ARTICLE

Management of Implantable Cardioverter Defibrillators in End-of-Life Care

Nathan E. Goldstein, MD; Rachel Lampert, MD; Elizabeth Bradley, PhD; Joanne Lynn, MD, MA, MS; and Harlan M. Krumholz, MD

7 December 2004 | Volume 141 Issue 11 | Pages 835-838

Background: Implantable cardioverter defibrillators (ICDs) can prevent premature death from an arrhythmia but may also prolong the dying process and make it more distressing.

Objective: To describe the frequency, timing, and correlates of discussions about deactivating ICDs.

Design: Retrospective cohort study.

Setting: Telephone survey.

Participants: Next of kin of patients with ICDs who died of any cause. Of 136 next of kin contacted, 100 (74%) participated.

Measurements: Incidence of discussions about deactivating ICDs and timing of last shock from ICD.

Results: Next of kin reported that clinicians discussed deactivating the ICD in only 27 of the 100 cases. Most discussions occurred in the last few days of life. Family members reported that 8 patients received a shock from their ICD in the minutes before death.

Limitations: This retrospective survey relied on the reports of next of kin.

Conclusions: Next of kin reported that clinicians discussed deactivating ICDs with few patients. Individuals who choose to receive this device should have the opportunity to choose to discontinue it as death approaches.

Editors' Notes Context Implantable cardioverter defibrillators (ICDs) reduce the likelihood of arrhythmic death, but ICD discharges are uncomfortable. Some terminally ill patients may prefer to deactivate their ICDs when maximizing comfort has taken priority over prolonging life. Contribution In this survey of the next of kin of 100 patients who died with ICDs in place, only 27 reported that physicians discussed deactivation of the ICD and often did so only in the last few days of life. Implications Discussing ICD deactivation may improve the care of patients who are nearing death. –The Editors

 

Author and Article Information

From the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut; and the Washington Home Center for Palliative Care Studies, Washington, DC.

Acknowledgments: The authors thank Barbara Mendes and Joanne McGloin at the Program on Aging, Yale University, for their assistance with data collection. The After-Death Bereaved Family Interview of the Toolkit of Instruments to Measure End-of-Life Care is used with permission of Joan Teno, MD, MS, Center for Gerontology and Health Care Research, Brown Medical School, Providence, Rhode Island.

Grant Support: Dr. Goldstein was a Robert Wood Johnson Clinical Scholar funded by the Department of Veterans Affairs during the course of this study. Dr. Lampert is supported by American Heart Association grant #0030190N. Dr. Bradley is supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation (Donaghue Investigator Award grant #02-102) and the Claude D. Pepper Older Americans Independence Center at Yale University (#P30AG21342). Dr. Lynn is supported by The Washington Home Center for Palliative Care Studies.

Potential Financial Conflicts of Interest:Expert testimony: J. Lynn (Medicare Coverage Advisory Committee).

Requests for Single Reprints: Nathan E. Goldstein, MD, Department of Geriatrics, Mount Sinai Medical Center, Box 1070, One Gustave L. Levy Place, New York, NY 10029; e-mail, nathan.goldstein{at}mssm.edu.

Current Author Addresses: Dr. Goldstein: Brookdale Department of Geriatrics, Box 1070, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029.

Dr. Lampert: Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, CT 06510.

Dr. Bradley: Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520.

Dr. Lynn: The Washington Home Center for Palliative Care Studies, 3720 Upton Street, NW, Washington, DC 20016.

Dr. Krumholz: Clinical Scholars Program, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT 06520-8025.

Author Contributions: Conception and design: N.E. Goldstein, R. Lampert, J. Lynn, H.M. Krumholz.

Analysis and interpretation of the data: N.E. Goldstein, R. Lampert, E. Bradley, J. Lynn, H.M. Krumholz.

Drafting of the article: N.E. Goldstein.

Critical revision of the article for important intellectual content: N.E. Goldstein, R. Lampert, E. Bradley, J. Lynn, H.M. Krumholz.

Final approval of the article: N.E. Goldstein, R. Lampert, E. Bradley, J. Lynn, H.M. Krumholz.

Provision of study materials or patients: R. Lampert.

Statistical expertise: N.E. Goldstein.

Obtaining of funding: H.M. Krumholz.

Administrative, technical, or logistic support: N.E. Goldstein.

Collection and assembly of data: N.E. Goldstein.

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