Patients With ICDs Might Want Shut-Off in Some Scenarios

Jim Kling

May 09, 2012

May 9, 2012 (Seattle, Washington) — Many patients with an implantable cardioverter defibrillator (ICD) would consider deactivating the device in specific situations, according to research presented here at the American Geriatrics Society 2012 Annual Scientific Meeting.

ICDs prolong the lives of patients with symptomatic heart failure and ejection fractions below 35%. They operate by delivering painful shocks that some patients describe as a "kick in the chest." According to previous research, family members report that about 8% of patients with ICDs experience such a shock in the last few minutes of life.

ICDs can be turned off so that no shocks will be administered, but previous surveys have indicated that ICD patients prefer that it not be deactivated. However, that research asked about very specific scenarios, such as constant shortness of breath and receiving shocks every day. "Would patients consider deactivation given other broad health states? We thought maybe we should ask them about more general states of functioning," John Dodson, MD, a postdoctoral fellow in geriatrics and cardiology at the Yale University School of Medicine in New Haven, Connecticut, who presented the research, told Medscape Medical News.

The researchers conducted a cross-sectional telephone survey of patients 50 years and older at an electrophysiology lab in Connecticut. They collected sociodemographic factors, clinical characteristics, and self-reported functional status.

The team then asked patients if they would consider deactivation of their ICD in any of 5 specific scenarios: permanent inability to get out of bed; permanent memory problems; being a burden to family members; dependence on a breathing machine for longer than 1 month; and advanced incurable disease.

Those who responded "possibly yes" or "definitely yes" were recorded as considering deactivation in that scenario.

In all, 95 patients completed the survey (mean age, 71 years; 28% female; 18% nonwhite). Of these, 71% of respondents indicated that they would consider ICD deactivation in at least 1 scenario, but there was significant variation by scenario.

Deactivation was most likely to be considered for incurable disease (58 of 95), followed by reliance on a breathing machine for longer than 1 month (57 of 95), being a burden to family members (48 of 95), permanent memory problems (41 of 95), and being permanently unable to get out of bed (23 of 95).

The researchers read a script to survey participants explaining what an ICD does and the potential for it to be deactivated. "It's along the lines of informed consent. [Previous] surveys were self-administered or administered in person, but it wasn't clear that the patients actually knew what the device did. We were very explicit that it delivers a lifesaving shock, but that it could be physically deactivated," said Dr. Dodson.

The study did not address the choices that patients actually made when faced with the described situations. "We don't have longitudinal data, so we don't know if [their declared] preferences influence the decisions they make in the future. One thing we looked at was the level of disability and its effect on patients' preferences for deactivation. We found that patients with disability in instrumental activities of daily living were more likely to [consider] deactivation than patients without disabilities, which suggests that as patients become more disabled, they're more open to making this decision. I wouldn't say this is definitive, but it's something that we were able to explore," Dr. Dodson added.

This study underscores the importance of advanced directives and patient communication, according to Sandra Sanchez-Reilly, MD, associate professor of geriatrics at the University of Texas Health Sciences Center in San Antonio, who moderated the session.

"Very frequently patients don't have conversations about turning off defibrillators or other arrhythmia-related cardio devices, and they suffer a great deal. Having conversations during doctor visits in preparation [for such decisions] is beneficial to improved quality of life. About 8% of patients [with ICDs] have the defibrillator fire while they're dying. That could be brought to 0% just by conversations," Dr. Sanchez-Reilly told Medscape Medical News.

Dr. Dodson and Dr. Sanchez-Reilly have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2012 Annual Scientific Meeting: Abstract P2. Presented May 3, 2012.