Implantable Cardioverter Defibrillators and End-of-Life Care

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The summary below is from the full report titled "Management of Implantable Cardioverter Defibrillators in End-of-Life Care." It is in the 7 December 2004 issue of Annals of Internal Medicine (volume 141, pages 835-838). The authors are N.E. Goldstein, R. Lampert, E. Bradley, J. Lynn, H.M. Krumholz.

What is the problem and what is known about it so far?

Cardiac arrest is an abnormal heart rhythm that causes the heart to suddenly stop beating. Doctors treat cardiac arrest by using electric shocks that help the heart return to a normal rhythm. Doctors can apply the electricity externally to the chest or can place an electrical device under the skin to detect abnormal heart rhythms and immediately apply an electric shock to the heart. These devices are called implantable cardioverter defibrillators or ICDs. The devices can prolong life, which is usually the desired goal. However, patients with ICDs who are seriously ill and nearing death may no longer want to prolong life or suffer the discomfort that ICD shocks cause. It is not known how often doctors discuss turning off ICDs with patients nearing death who have the device. Turning off the device would let patients die a less uncomfortable death without the discomfort of electric shocks.

Why did the researchers do this particular study?

To see whether dying patients with ICDs received electric shocks as they approached death and to see how often doctors discussed the option of turning off the ICDs with patients.

Who was studied?

The researchers interviewed the next of kin of 100 patients with ICDs who died between 1997 and 2002 at a teaching hospital in the northeastern United States.

How was the study done?

The researchers telephoned patients' next of kin to ask questions about end-of-life care and the patients' experiences. The questions included the timing of the last shock that the patient received from the ICD and whether (and when) the doctor had discussed the option of turning off the device with the patient.

What did the researchers find?

27 of the 100 patients received ICD shocks during the last month of life. Of these, 8 patients received shocks during the minutes before death. Next of kin reported that doctors discussed the option of turning off the devices with 27 of the 100 patients. Most of the discussions occurred in the days just before the patient's death.

What are the limitations of the study?

The study was done at 1 hospital, and the findings may not apply to other hospitals or settings. Also, the study relied on the memories of next of kin, which could have been faulty.

What are the implications of the study?

Only some patients with ICDs are offered the option to turn off the devices before death. Discussions about turning off the device tend to be a reaction to patient distress immediately before death, not a part of end-of-life planning. Doctors could lessen patient suffering near the end of life by having these discussions in advance.