COMMENTARY

Deactivating Implantable Cardioverter-Defibrillators Near the End of Life

Betty R. Ferrell, PhD, RN

Disclosures

April 19, 2018

Palliative Care for Heart Failure

Heart failure accounts for 1 in 9 deaths in the United States, with a 40% mortality rate in the first year after diagnosis and 75% at 5 years after diagnosis. Consequently, the increase in heart failure seen in our aging society has become a major focus for palliative care. Advances in treatment have allowed patients to live for extended periods of time, yet often with significant symptom burden and quality-of-life concerns. Advanced technologies—such as implantable cardioverter-defibrillators (ICDs)—have extended life yet have also created clinical challenges, including decisions about when and how to deactivate these devices to prevent inappropriate electrical shocks in patients nearing the end of life.[1,2,3]

In a recent article, Herman and colleagues[4] presented a systematic review of the deactivation of ICDs in patients with end-stage heart failure. The investigators screened 211 articles, but only nine studies met their criteria of involving patients with heart failure and ICDs and focusing on issues related to deactivation of the devices and end-of-life care. These nine studies included a total of 24,770 patients and 362 physicians.

This review revealed that discussions with patients about deactivating their ICDs were uncommon. Many patients did not fully understand how an ICD works or the impact that ICDs can have on their lives. Typically, patients with heart failure had not considered deactivating their ICDs; indeed, many were not aware that deactivating these devices at some point was even an option, and consent forms for ICD placement rarely addressed the need to eventually discontinue them or how this might occur. In reality, ICDs were often not deactivated until the patient's condition took a marked turn for the worse, and the patient was nearing death.

Viewpoint

This study addresses a very important concern related to the population of patients living with heart failure, currently estimated at 5.74 million people in the United States and expected to increase by 46% by 2030.

Clearly, patients are not well-informed about the role that ICDs play in their health or the very predictable clinical decision to deactivate their ICDs as they near the end of life. The findings of this review also reinforce the well-established need for advance directives of patients with heart failure to include ICD management and deactivation.

The issue of ICD use to sustain life in heart failure can serve as a model for other life-prolonging technologies. We need to test educational approaches and policies that balance the benefits of technology with the burdens and realities of discontinuing the technology at life's end.[5,6]

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