Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features
ICDs in end-stage heart failure Stephen J Pettit,1 Susan Browne,2 Karen J Hogg,1 Derek T Connelly,1 Roy S Gardner,1 Carl R May,3 Una Macleod,4 Frances S Mair2 1Scottish
National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK 2General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK 3Department of Health Sciences, University of Southampton, Southampton, UK 4 Hull York Medical School, University of Hull, Hull, UK Correspondence to Stephen J Pettit, Golden Jubilee National Hospital, Scottish National Advanced Heart Failure Service, Agamemnon Street, Clydebank, Glasgow, G81 4DY, UK; [email protected] Received 28 November 2011 Accepted 19 March 2012
ABSTRACT Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients with chronic heart failure but prognostic benefit is likely to attenuate with progression to end-stage heart failure. The incidence of multiple futile ICD shocks before death is uncertain. Only individual patients, supported by their healthcare professionals, can decide when ICD therapy becomes futile in end-stage heart failure. Despite consensus that ICD deactivation should be routinely discussed, this rarely occurs in clinical practice for many reasons including uncertainty about when to initiate these discussions and reluctance to confront death and dying. Patient and carer opinions about end-stage heart failure and ICD deactivation may not meet professional expectations. Future research should focus on these opinions and examine interventions that bridge the gap between best practice and the reality of current clinical practice. INTRODUCTION Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at high risk of sudden arrhythmic death. The majority of ICD recipients have chronic heart failure with underlying severe left ventricular systolic dysfunction. ICDs do not prevent non-arrhythmic death and ultimately, due to comorbidities and competing mechanisms of death, all ICD recipients will die. We explore issues relating to the use and deactivation of ICDs in patients with end-stage heart failure. We include quotes from patients, carers and healthcare professionals that are taken from focus groups and semistructured interviews conducted as part of research commissioned by ‘Caring Together’, a 5-year collaborative programme between Marie Curie Cancer Care, the British Heart Foundation and National Health Service Greater Glasgow and Clyde which aims to improve palliative care for patients with advanced heart failure.
DO ICDS PROLONG LIFE IN END-STAGE HEART FAILURE? End-stage heart failure may be defi ned as the presence of heart failure symptoms at rest or with minimal exertion, despite optimal medical therapy, in a patient who is not suitable for heart transplantation or mechanical circulatory support.1 There are little data about the use of ICDs in patients with endstage heart failure. Patients with New York Heart Association (NYHA) class IV heart failure symptoms or a life expectancy of less than 1 year were excluded from almost all randomised controlled trials of ICD therapy. As such, there is little evidence, either for or against, a survival benefit from ICDs in patients with NYHA class IV heart failure symptoms. 94
There is confl icting evidence about the survival benefit from ICDs in patients with NYHA class III heart failure symptoms. The DEFINITE trial of ICDs in non-ischaemic dilated cardiomyopathy showed that survival benefit from an ICD was confi ned to patients with NYHA class III symptoms. 2 In SCD-HEFT, the largest trial of ICDs in a heart failure population, survival benefit from an ICD was confi ned to NYHA class II patients; no benefit was seen in those with NYHA class III symptoms. 3 4 A post hoc analysis of SCD-HEFT using the Seattle Heart Failure Score, one of the best validated prognostic tools in heart failure, showed that the quintile of the trial population with the worst prognosis at baseline did not derive survival benefit from an ICD. 5 One possible explanation is that patients with severe heart failure may not survive long enough to accrue prognostic benefit from an ICD. Kaplan–Meier survival analysis from SCD-HEFT showed no survival benefit until 1 year after ICD implantation. 3 Accordingly, international guidelines state that ICDs should only be implanted when patients are expected to survive with good functional status for more than 1 year, unless being considered for cardiac transplantation.6 While it is accepted that ICDs should not be implanted when heart failure patients are in their last year of life, many patients progress to end-stage heart failure in the years after ICD implantation. As heart failure symptoms and left ventricular systolic dysfunction get worse, there is an increased likelihood of ventricular arrhythmias and appropriate ICD shocks.7 Simultaneously, there is an increased risk of non-arrhythmic modes of death, such as pump failure.8 In the MADIT-2 trial, the efficacy of ICDs was maintained after fi rst heart failure hospitalisation, but attenuated during extended follow-up in patients with more severe heart failure symptoms.9 10 No studies have sought to determine when the prognostic benefit of ICD therapy is lost as patients develop endstage heart failure and whether this point can be identified prospectively.
HOW MUCH ICD THERAPY DO PATIENTS RECEIVE BEFORE DEATH? Clinical trials have not described the burden of ICD therapy before death. A European registry described 442 heart failure patients with a primary or secondary prevention ICD. There were 73 deaths during a median follow-up of 3.6 years. Appropriate ICD therapy occurred before death in 44 of 73 (60%) patients. The pattern was similar in the 34 patients who ultimately died of heart failure; appropriate ICD therapy occurred before
BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features death in 23 of 34 (68%) patients.11 Similar fi ndings were seen in another European registry that described 463 patients with a primary or secondary prevention cardiac resynchronisation therapy-defibrillator device. There were 85 deaths during a median follow-up of 30.5 months, of whom 45 (53%) patients received appropriate ICD therapy before death.12 A retrospective cohort study reviewed the records of 63 patients who died with an ICD while under follow-up at a single device clinic over 10 years. A terminal diagnosis leading to ICD deactivation was identified before death in 32% of patients. For patients with active ICDs at the time of death, 21% received an ICD shock in the 30 days before death. However, for patients with deactivated ICDs, 15% still received an ICD shock in the 30 days before death. The small difference between these two groups reflects the short time between ICD deactivation and death.13 ICD therapy before death is undesirable if the death is expected and occurs shortly after ICD therapy. There are case reports of patients who received multiple ICD shocks in their last hours or minutes, resulting in considerable distress for them and their relatives.14 15 A retrospective cohort study questioned the relatives of 100 patients who died with an ICD. Twenty-seven patients received ICD shocks in their last month of life and eight patients received ICD shocks in their last minutes of life. The study does not describe whether the futility of ICD therapy was apparent at the time of the shocks. However, do-not-resuscitate (DNR) orders were in place for 21 of these 27 patients, suggesting that the majority of these deaths were not unexpected.14 Ultimately, the futility of ICD therapy can only be determined by individual patients and depends on the amount of added life they feel is justified by an ICD shock. A better understanding of the risk of futile ICD therapy and the extent to which ICD deactivation reduces futile ICD therapy would be helpful when counselling patients about ICD deactivation.
WHEN DOES GUIDANCE SUGGEST ICD DEACTIVATION IS DISCUSSED? The European Society of Cardiology suggest ICD deactivation should be considered when it is clinically obvious that a patient is about to die, when a DNR order is in force and when impairment of quality of life is such that sudden death might be considered a relief.16 The British Heart Foundation suggest that physicians should initiate discussions about ICD deactivation when markers of poor prognosis in advanced heart failure are present.15 A variety of different tools exist to assess prognosis in heart failure, ranging from single clinical variables to complex scoring systems and, most importantly, clinical acumen. However, prognostication in heart failure remains challenging and it can be difficult to know when to discuss ICD deactivation.16 A consensus statement was recently published by six American and European professional societies.17 The writing group comprised a broad range of professionals, including electrophysiologists, palliative care physicians, geriatricians, psychiatrists, nurses, and experts in law, ethics and divinity. There was less patient and carer perspective; only a single patient contributed to the writing group. The group emphasised the central role of the patient in deciding when their ICD should be deactivated. They suggest that counselling about ICD deactivation should be an ongoing process that starts before implant and continues as the patient’s health changes. Deactivation discussions should be prompted by events including multiple ICD shocks, repeated hospitalisation, DNR orders or at the end of life. The document is clear that the physician’s BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
role is advisory. Only the patient can decide when the burden of an active ICD exceeds the perceived benefits. The authors assert that patients should be supported irrespective of their decision, which may seem illogical to physicians, such as leaving an ICD active while having a DNR order or leaving antitachycardia pacing active while deactivating shock therapy.
WHEN IS ICD DEACTIVATION DISCUSSED IN CLINICAL PRACTICE? There appears to be a gap between guidance and practice with respect to ICD deactivation. In a series of semistructured interviews with 15 ICD recipients, none recalled a conversation about ICD deactivation prior to implantation.18 The European Heart Rhythm Association (EHRA) conducted a survey of cardiologists at 47 ICD-implanting centres in 2010. Contrary to international consensus, the possibility of future ICD deactivation was only discussed by 4% of cardiologists before implantation.19 From the limited evidence available, it appears that future ICD deactivation is rarely discussed at the point of implantation. Deactivation discussions occur more frequently as patients deteriorate, but less frequently than the level recommended in international guidance. In the EHRA survey, only 11% of cardiologists were regularly involved in ICD deactivation and only 4% of cardiologists provided written information about options for ICD management in terminally ill patients. These were large centres; 94% implanted more than 50 ICDs per year and 61% conducted more than 500 follow-ups per year.19 In a retrospective cohort study of 100 relatives of patients who died with an ICD, clinicians only discussed ICD deactivation before death in 27% of cases. When discussions occurred, they were close to the time of death; 75% in the last days of life, 22% in the last hours of life and 4% in the last minutes of life.14 Interestingly, reluctance to deactivate ICDs at the end of life is not confi ned to cardiologists and hospital care. In a survey of 900 hospices in the USA, 40% of institutions had at least one patient who had received multiple ICD shocks at the hospice during the preceding year. Of patients with an active ICD, only 42% had the shocking function of their ICD deactivated while receiving hospice care. In addition, only 10% of hospices had policies that addressed ICD deactivation at the end of life. 20 Failure to discuss ICD deactivation may be part of a wider problem; a recent systematic review suggests that end of life care is rarely discussed with heart failure patients. 21 Many patients do not appreciate the seriousness of their condition. Clinicians avoid discussing end of life care due to concerns about causing alarm and destroying hope. Instead, clinicians wait for cues from patients that are unlikely to come if the patients themselves are unaware of their poor prognosis. If this remains the norm for end-stage heart failure patients, it is not surprising that discussions regarding ICD deactivation are not commonplace.
WHAT DO CLINICIANS THINK ABOUT DEACTIVATING ICDS? There are many reasons why clinicians may not discuss ICD deactivation despite consensus that this is legally and ethically justifi able in certain circumstances. There is significant variation in the circumstances in which clinicians think that ICD deactivation is appropriate. In an EHRA survey, 83% of cardiologists at ICD-implanting centres thought that ICDs should be deactivated after multiple appropriate shocks in dying patients, but only 48.9% of these cardiologists thought that ICDs should be deactivated in end-stage heart failure.19 95
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features Several studies suggest a reluctance to discuss ICD deactivation. A US group conducted semistructured interviews with 12 fully trained clinicians who have personal experience of ICD deactivation. Participants included cardiologists (four), electrophysiologists (two), internists (two) and geriatricians (two). Many of these clinicians were reluctant to discuss ICD deactivation due to the difficult nature of conversations about death, particularly when they do not have an established relationship with the patient in question.22 A second group conducted a survey of 185 clinicians in a single US hospital. Only 55% of respondents were comfortable discussing the withdrawal of ICD therapy. Participants were less specialised, including internists (150), electrophysiologists (36), cardiologists (13), pulmonologists (13) and geriatricians (eight). 23 In a US-wide study of 147 electrophysiologists, cardiologists, internists and geriatricians with experience of ICD management, 86% of respondents felt comfortable dealing with ICD patients at the end of life. However, 62% of respondents lacked confidence in assessing life expectancy in ICD patients and 64% lacked confidence in predicting the possibility of ICD shocks near the end of life. Interestingly, and in contrast to patient surveys, most physicians thought their patients understood why they had an ICD, were aware of the option of deactivation and wished to be involved in decisions about ICD deactivation. 24 Very little is known about the attitudes of non-US clinicians and non-hospital clinicians, such as general practitioners, towards ICD deactivation. 25 Ongoing work in the UK involving health professionals who manage people with end-stage heart failure has highlighted that non-cardiologists may not
Box 1 Health professionals lack knowledge/support/ resources General practitioners (GPs) lack knowledge about implantable cardioverter defibrillators (ICDs) and ICD deactivation: INTERVIEWER (to GP focus group): I wondered what your views would be about defibrillator conversations – what you think should be happening? GP: Jings! We don’t even talk to them about end of life. You guess that one. I have no experience of that whatsoever. Nor have I ever come across anyone that that has been an issue for that anyone else has had to have that discussion with. Ever. Clinicians lack resources to discuss ICD deactivation: We, all the staff, the nursing staff and myself found it very difficult to discuss with X and we discussed it over a matter of weeks and months. And we also found it difficult because X maybe wasn’t quite so realistic about his prognosis and we once explained the pacemaker part of his wouldn’t be switched off and that this was just a preventative thing to stop it firing and causing distress. After that he was maybe a bit happier because certainly at that point he felt he was suffering a bit in terms of his symptom control. It was a very difficult process. I must admit I didn’t feel I had an awful lot of written material. I felt I could have done with something to back up my information. And that’s maybe something for me to look into for the future but I felt I was kind of repeatedly discussing this with him and didn’t have an awful lot of information. I felt he wanted to read something or he wanted to know something and he just couldn’t grasp it so it took us maybe 2 or 3 months to discuss it through. Geriatrician. 96
understand ICDs and may feel unsupported in discussions about ICD deactivation (box 1).
WHAT DO PATIENTS AND CARERS THINK ABOUT DEACTIVATING ICDS? There are little published data about patient attitudes towards ICD deactivation. In a series of semistructured interviews, 15 ICD recipients from an electrophysiology clinic at a US academic medical centre were asked about ICD deactivation. Most patients were keen to talk about their ICD, but reluctant to engage in conversations about deactivation. This reluctance extended to discussing ICD deactivation with their physician; several patients thought that their physician should take such decisions. Patients displayed high levels of anxiety about future ICD shocks, particularly those patients who had previously received ICD shocks. Very few patients knew that the shock function of their ICD could be deactivated. Many patients had significant misconceptions about the function of their ICD, making it difficult to contribute to informed decisions about ICD deactivation.18 Ongoing work in the UK involving patients with end-stage heart failure has reinforced the concept that many patients do not understand their condition, their prognosis or the function of an ICD (box 2). These factors make it very difficult to discuss ICD deactivation. Recent research has cast doubt on the common assumption that older individuals with end-stage heart failure favour quality of life over longevity. Among 622 patients aged >60 years with chronic heart failure, 74% were not willing to trade survival time for improved quality of life and 51% wished to be resuscitated if necessary. 26 Awareness of such attitudes should be borne in mind during discussions about ICD deactivation. Although there are very little published data, ICD deactivation is also an extremely contentious issue for the carers of patients with end-stage heart failure. Carers of patients with end-stage heart failure may be distressed by the idea of ICD deactivation and may struggle to understand the rationale for ICD deactivation (box 3).
SUMMARY The prognostic benefit of an ICD is likely to attenuate with progression to end-stage heart failure. The risk of multiple futile ICD shocks before death is uncertain, but probably occurs in less than
Box 2 Patients have limited understanding about their condition Patients have limited understanding of their diagnosis: The left ventricle isn’t working properly. When I had the heart attack it damaged it a bit so that is what I was told, that is all I know. Female, age 72 Patients have limited understanding of their prognosis: I mean I’m not an expert but I’ve got an idea of what’s happening. I know what’s caused this, it doesn’t scare me. I mean if it was killing me, well it is, I suppose, but I just forget that bit. I don’t think I’m going to die next week. Male, age 67 Patients have limited understanding of implantable cardioverter defibrillator function: I have got a what do you call it fitted, a defibrillator which helps to keep you alive and the medicine that they will give me will hopefully monitor my heart system. But that is what they have told me. I am actually quite floored with it. Male, age 65 BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features
Box 3 Carer perspectives about implantable cardioverter defibrillator deactivation discussions And even last time I had said to her ‘why is death imminent?’, talking about switching off the defibrillator and when they do that. I mean I don’t think we need to even think about doing that because at the end of the day the worse thing that happens is it fires and fires and fires and you get a three minute response and somebody is here…., I don’t think we have to dwell on that and, you know, that sort of thing. I can understand them talking about whether you want to be resuscitated or not, I think that is quite straightforward. Carer And then he says the defibrillator, he didn’t say he was taking it out, he says he was going to switch off the resus button. And again I said to him and why are you doing that? And he says ‘because its mainly, it can be very distressing because if X takes a heart attack and it doesn’t bring him round it would keep going off and you would get into an awful state’ and all that and I said ‘well I’m quite willing to take that chance’ I said, so just I prefer you to leave the defib as it is. Carer 10% of patients. The futility of ICD therapy can only be decided by an individual patient with the support of their healthcare professionals. Patient opinions about the amount of additional life that is justified by an ICD shock may not match professional expectations. Despite consensus that ICD deactivation should be routinely discussed, this rarely occurs in clinical practice. It is likely that many patients with end-stage heart failure die without having the opportunity to discuss ICD deactivation. Uncertainty about when to initiate discussions and reluctance by both doctors and patients to confront death and dying contribute to this problem. Non-specialists may also lack knowledge or feel unsupported, making ICD deactivation discussions less likely or more challenging. However, the issue should be considered in the wider context of end of life care planning in a population with suboptimal understanding of their condition and prognosis. We need to know more about how patients, carers, medical and nursing professionals understand the problem of ICD deactivation. We need to study interventions that might assist in crossing the translational gap between current ideas about ‘best practice’ and the realities of end-stage heart failure. Acknowledgements This research is supported by the Caring Together programme http://www.mariecurie.org.uk/caringtogether a partnership programme by Marie Curie Cancer Care, British Heart Foundation Scotland and NHS Greater Glasgow and Clyde. Funding KH, FM, SB, UM and CRM have received funding from the Caring Together programme which is jointly funded by British Heart Foundation Scotland, Marie Curie Cancer Care and NHS Greater Glasgow and Clyde. SP is currently funded by an unrestricted educational grant from St Jude Medical. Competing interests None. Ethics approval Approval provided by the West of Scotland Research Ethics Service (10/S0701/20). Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005;112:e154–e235.
BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
2. Kadish A, Dyer A, Daubert JP, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004;350:2151–2158. 3. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverterdefibrillator for congestive heart failure. N Engl J Med 2005;352:225–237. 4. Packer DL, Prutkin JM, Hellkamp AS, et al. Impact of implantable cardioverterdefibrillator, amiodarone, and placebo on the mode of death in stable patients with heart failure: analysis from the sudden cardiac death in heart failure trial. Circulation 2009;120:2170–2176. 5. Levy WC, Lee KL, Hellkamp AS, et al. Maximizing survival benefit with primary prevention implantable cardioverter-defibrillator therapy in a heart failure population. Circulation 2009;120:835–842. 6. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 2006;8:746–837. 7. Whang W, Mittleman MA, Rich DQ, et al. Heart failure and the risk of shocks in patients with implantable cardioverter defibrillators: results from the Triggers Of Ventricular Arrhythmias (TOVA) study. Circulation 2004;109:1386–1391. 8. Mozaffarian D, Anker SD, Anand I, et al. Prediction of mode of death in heart failure: the Seattle Heart Failure Model. Circulation 2007;116:392–398. 9. Goldenberg I, Moss AJ, Hall WJ, et al. Causes and consequences of heart failure after prophylactic implantation of a defibrillator in the multicenter automatic defibrillator implantation trial II. Circulation 2006;113:2810–2817. 10. Goldenberg I, Gillespie J, Moss AJ, et al. Long-term benefit of primary prevention with an implantable cardioverter-defibrillator: an extended 8-year follow-up study of the Multicenter Automatic Defibrillator Implantation Trial II. Circulation 2010;122:1265–1271. 11. Koller MT, Schaer B, Wolbers M, et al. Death without prior appropriate implantable cardioverter-defibrillator therapy: a competing risk study. Circulation 2008;117:1918–1926. 12. Theuns DA, Schaer BA, Soliman OI, et al. The prognosis of implantable defibrillator patients treated with cardiac resynchronization therapy: comorbidity burden as predictor of mortality. Europace 2011;13:62–69. 13. Lewis WR, Luebke DL, Johnson NJ, et al. Withdrawing implantable defibrillator shock therapy in terminally ill patients. Am J Med 2006;119:892–896. 14. Goldstein NE, Lampert R, Bradley E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med 2004;141: 835–838. 15. Beattie J. Implantable cardioverter defibrillators in patients who are reaching the end of life. London: British Heart Foundation, 2007. 16. Jaarsma T, Beattie JM, Ryder M, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009;11:433–443. 17. Lampert R, Hayes DL, Annas GJ, 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. 18. Goldstein NE, Mehta D, Siddiqui S, et al. ‘That’s like an act of suicide’ patients’ attitudes toward deactivation of implantable defibrillators. J Gen Intern Med 2008;23 Suppl 1:7–12. 19. Marinskis G, van Erven L; EHRA Scientific Initiatives Committee. Deactivation of implanted cardioverter-defibrillators at the end of life: results of the EHRA survey. Europace 2010;12:1176–1177. 20. Goldstein N, Carlson M, Livote E, et al. Brief communication: Management of implantable cardioverter-defibrillators in hospice: A nationwide survey. Ann Intern Med 2010;152:296–299. 21. Barclay S, Momen N, Case-Upton S, et al. End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis. Br J Gen Pract 2011;61:e49–e62. 22. Goldstein NE, Mehta D, Teitelbaum E, et al. “It’s like crossing a bridge” complexities preventing physicians from discussing deactivation of implantable defibrillators at the end of life. J Gen Intern Med 2008;23 Suppl 1:2–6. 23. Kramer DB, Kesselheim AS, Brock DW, et al. Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment. Heart Rhythm 2010;7:1537–1542. 24. Goldstein N, Bradley E, Zeidman J, et al. Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians. J Am Coll Cardiol 2009;54:371–373. 25. Russo JE. Deactivation of ICDs at the end of life: a systematic review of clinical practices and provider and patient attitudes. Am J Nurs 2011;111:26–35. 26. Brunner-La Rocca H-P, Rickenbacher P, Muzzarelli S, et al. End-of-life preferences of elderly patients with chronic heart failure. Eur Heart J 2012;33:752–759..
97
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
ICDs in end-stage heart failure Stephen J Pettit, Susan Browne, Karen J Hogg, Derek T Connelly, Roy S Gardner, Carl R May, Una Macleod and Frances S Mair BMJ Support Palliat Care 2012 2: 94-97
doi: 10.1136/bmjspcare-2011-000176 Updated information and services can be found at: http://spcare.bmj.com/content/2/2/94
These include:
References Email alerting service
This article cites 25 articles, 11 of which you can access for free at: http://spcare.bmj.com/content/2/2/94#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Features
ICDs in end-stage heart failure Stephen J Pettit,1 Susan Browne,2 Karen J Hogg,1 Derek T Connelly,1 Roy S Gardner,1 Carl R May,3 Una Macleod,4 Frances S Mair2 1Scottish
National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK 2General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK 3Department of Health Sciences, University of Southampton, Southampton, UK 4 Hull York Medical School, University of Hull, Hull, UK Correspondence to Stephen J Pettit, Golden Jubilee National Hospital, Scottish National Advanced Heart Failure Service, Agamemnon Street, Clydebank, Glasgow, G81 4DY, UK; [email protected] Received 28 November 2011 Accepted 19 March 2012
ABSTRACT Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients with chronic heart failure but prognostic benefit is likely to attenuate with progression to end-stage heart failure. The incidence of multiple futile ICD shocks before death is uncertain. Only individual patients, supported by their healthcare professionals, can decide when ICD therapy becomes futile in end-stage heart failure. Despite consensus that ICD deactivation should be routinely discussed, this rarely occurs in clinical practice for many reasons including uncertainty about when to initiate these discussions and reluctance to confront death and dying. Patient and carer opinions about end-stage heart failure and ICD deactivation may not meet professional expectations. Future research should focus on these opinions and examine interventions that bridge the gap between best practice and the reality of current clinical practice. INTRODUCTION Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at high risk of sudden arrhythmic death. The majority of ICD recipients have chronic heart failure with underlying severe left ventricular systolic dysfunction. ICDs do not prevent non-arrhythmic death and ultimately, due to comorbidities and competing mechanisms of death, all ICD recipients will die. We explore issues relating to the use and deactivation of ICDs in patients with end-stage heart failure. We include quotes from patients, carers and healthcare professionals that are taken from focus groups and semistructured interviews conducted as part of research commissioned by ‘Caring Together’, a 5-year collaborative programme between Marie Curie Cancer Care, the British Heart Foundation and National Health Service Greater Glasgow and Clyde which aims to improve palliative care for patients with advanced heart failure.
DO ICDS PROLONG LIFE IN END-STAGE HEART FAILURE? End-stage heart failure may be defi ned as the presence of heart failure symptoms at rest or with minimal exertion, despite optimal medical therapy, in a patient who is not suitable for heart transplantation or mechanical circulatory support.1 There are little data about the use of ICDs in patients with endstage heart failure. Patients with New York Heart Association (NYHA) class IV heart failure symptoms or a life expectancy of less than 1 year were excluded from almost all randomised controlled trials of ICD therapy. As such, there is little evidence, either for or against, a survival benefit from ICDs in patients with NYHA class IV heart failure symptoms. 94
There is confl icting evidence about the survival benefit from ICDs in patients with NYHA class III heart failure symptoms. The DEFINITE trial of ICDs in non-ischaemic dilated cardiomyopathy showed that survival benefit from an ICD was confi ned to patients with NYHA class III symptoms. 2 In SCD-HEFT, the largest trial of ICDs in a heart failure population, survival benefit from an ICD was confi ned to NYHA class II patients; no benefit was seen in those with NYHA class III symptoms. 3 4 A post hoc analysis of SCD-HEFT using the Seattle Heart Failure Score, one of the best validated prognostic tools in heart failure, showed that the quintile of the trial population with the worst prognosis at baseline did not derive survival benefit from an ICD. 5 One possible explanation is that patients with severe heart failure may not survive long enough to accrue prognostic benefit from an ICD. Kaplan–Meier survival analysis from SCD-HEFT showed no survival benefit until 1 year after ICD implantation. 3 Accordingly, international guidelines state that ICDs should only be implanted when patients are expected to survive with good functional status for more than 1 year, unless being considered for cardiac transplantation.6 While it is accepted that ICDs should not be implanted when heart failure patients are in their last year of life, many patients progress to end-stage heart failure in the years after ICD implantation. As heart failure symptoms and left ventricular systolic dysfunction get worse, there is an increased likelihood of ventricular arrhythmias and appropriate ICD shocks.7 Simultaneously, there is an increased risk of non-arrhythmic modes of death, such as pump failure.8 In the MADIT-2 trial, the efficacy of ICDs was maintained after fi rst heart failure hospitalisation, but attenuated during extended follow-up in patients with more severe heart failure symptoms.9 10 No studies have sought to determine when the prognostic benefit of ICD therapy is lost as patients develop endstage heart failure and whether this point can be identified prospectively.
HOW MUCH ICD THERAPY DO PATIENTS RECEIVE BEFORE DEATH? Clinical trials have not described the burden of ICD therapy before death. A European registry described 442 heart failure patients with a primary or secondary prevention ICD. There were 73 deaths during a median follow-up of 3.6 years. Appropriate ICD therapy occurred before death in 44 of 73 (60%) patients. The pattern was similar in the 34 patients who ultimately died of heart failure; appropriate ICD therapy occurred before
BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features death in 23 of 34 (68%) patients.11 Similar fi ndings were seen in another European registry that described 463 patients with a primary or secondary prevention cardiac resynchronisation therapy-defibrillator device. There were 85 deaths during a median follow-up of 30.5 months, of whom 45 (53%) patients received appropriate ICD therapy before death.12 A retrospective cohort study reviewed the records of 63 patients who died with an ICD while under follow-up at a single device clinic over 10 years. A terminal diagnosis leading to ICD deactivation was identified before death in 32% of patients. For patients with active ICDs at the time of death, 21% received an ICD shock in the 30 days before death. However, for patients with deactivated ICDs, 15% still received an ICD shock in the 30 days before death. The small difference between these two groups reflects the short time between ICD deactivation and death.13 ICD therapy before death is undesirable if the death is expected and occurs shortly after ICD therapy. There are case reports of patients who received multiple ICD shocks in their last hours or minutes, resulting in considerable distress for them and their relatives.14 15 A retrospective cohort study questioned the relatives of 100 patients who died with an ICD. Twenty-seven patients received ICD shocks in their last month of life and eight patients received ICD shocks in their last minutes of life. The study does not describe whether the futility of ICD therapy was apparent at the time of the shocks. However, do-not-resuscitate (DNR) orders were in place for 21 of these 27 patients, suggesting that the majority of these deaths were not unexpected.14 Ultimately, the futility of ICD therapy can only be determined by individual patients and depends on the amount of added life they feel is justified by an ICD shock. A better understanding of the risk of futile ICD therapy and the extent to which ICD deactivation reduces futile ICD therapy would be helpful when counselling patients about ICD deactivation.
WHEN DOES GUIDANCE SUGGEST ICD DEACTIVATION IS DISCUSSED? The European Society of Cardiology suggest ICD deactivation should be considered when it is clinically obvious that a patient is about to die, when a DNR order is in force and when impairment of quality of life is such that sudden death might be considered a relief.16 The British Heart Foundation suggest that physicians should initiate discussions about ICD deactivation when markers of poor prognosis in advanced heart failure are present.15 A variety of different tools exist to assess prognosis in heart failure, ranging from single clinical variables to complex scoring systems and, most importantly, clinical acumen. However, prognostication in heart failure remains challenging and it can be difficult to know when to discuss ICD deactivation.16 A consensus statement was recently published by six American and European professional societies.17 The writing group comprised a broad range of professionals, including electrophysiologists, palliative care physicians, geriatricians, psychiatrists, nurses, and experts in law, ethics and divinity. There was less patient and carer perspective; only a single patient contributed to the writing group. The group emphasised the central role of the patient in deciding when their ICD should be deactivated. They suggest that counselling about ICD deactivation should be an ongoing process that starts before implant and continues as the patient’s health changes. Deactivation discussions should be prompted by events including multiple ICD shocks, repeated hospitalisation, DNR orders or at the end of life. The document is clear that the physician’s BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
role is advisory. Only the patient can decide when the burden of an active ICD exceeds the perceived benefits. The authors assert that patients should be supported irrespective of their decision, which may seem illogical to physicians, such as leaving an ICD active while having a DNR order or leaving antitachycardia pacing active while deactivating shock therapy.
WHEN IS ICD DEACTIVATION DISCUSSED IN CLINICAL PRACTICE? There appears to be a gap between guidance and practice with respect to ICD deactivation. In a series of semistructured interviews with 15 ICD recipients, none recalled a conversation about ICD deactivation prior to implantation.18 The European Heart Rhythm Association (EHRA) conducted a survey of cardiologists at 47 ICD-implanting centres in 2010. Contrary to international consensus, the possibility of future ICD deactivation was only discussed by 4% of cardiologists before implantation.19 From the limited evidence available, it appears that future ICD deactivation is rarely discussed at the point of implantation. Deactivation discussions occur more frequently as patients deteriorate, but less frequently than the level recommended in international guidance. In the EHRA survey, only 11% of cardiologists were regularly involved in ICD deactivation and only 4% of cardiologists provided written information about options for ICD management in terminally ill patients. These were large centres; 94% implanted more than 50 ICDs per year and 61% conducted more than 500 follow-ups per year.19 In a retrospective cohort study of 100 relatives of patients who died with an ICD, clinicians only discussed ICD deactivation before death in 27% of cases. When discussions occurred, they were close to the time of death; 75% in the last days of life, 22% in the last hours of life and 4% in the last minutes of life.14 Interestingly, reluctance to deactivate ICDs at the end of life is not confi ned to cardiologists and hospital care. In a survey of 900 hospices in the USA, 40% of institutions had at least one patient who had received multiple ICD shocks at the hospice during the preceding year. Of patients with an active ICD, only 42% had the shocking function of their ICD deactivated while receiving hospice care. In addition, only 10% of hospices had policies that addressed ICD deactivation at the end of life. 20 Failure to discuss ICD deactivation may be part of a wider problem; a recent systematic review suggests that end of life care is rarely discussed with heart failure patients. 21 Many patients do not appreciate the seriousness of their condition. Clinicians avoid discussing end of life care due to concerns about causing alarm and destroying hope. Instead, clinicians wait for cues from patients that are unlikely to come if the patients themselves are unaware of their poor prognosis. If this remains the norm for end-stage heart failure patients, it is not surprising that discussions regarding ICD deactivation are not commonplace.
WHAT DO CLINICIANS THINK ABOUT DEACTIVATING ICDS? There are many reasons why clinicians may not discuss ICD deactivation despite consensus that this is legally and ethically justifi able in certain circumstances. There is significant variation in the circumstances in which clinicians think that ICD deactivation is appropriate. In an EHRA survey, 83% of cardiologists at ICD-implanting centres thought that ICDs should be deactivated after multiple appropriate shocks in dying patients, but only 48.9% of these cardiologists thought that ICDs should be deactivated in end-stage heart failure.19 95
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features Several studies suggest a reluctance to discuss ICD deactivation. A US group conducted semistructured interviews with 12 fully trained clinicians who have personal experience of ICD deactivation. Participants included cardiologists (four), electrophysiologists (two), internists (two) and geriatricians (two). Many of these clinicians were reluctant to discuss ICD deactivation due to the difficult nature of conversations about death, particularly when they do not have an established relationship with the patient in question.22 A second group conducted a survey of 185 clinicians in a single US hospital. Only 55% of respondents were comfortable discussing the withdrawal of ICD therapy. Participants were less specialised, including internists (150), electrophysiologists (36), cardiologists (13), pulmonologists (13) and geriatricians (eight). 23 In a US-wide study of 147 electrophysiologists, cardiologists, internists and geriatricians with experience of ICD management, 86% of respondents felt comfortable dealing with ICD patients at the end of life. However, 62% of respondents lacked confidence in assessing life expectancy in ICD patients and 64% lacked confidence in predicting the possibility of ICD shocks near the end of life. Interestingly, and in contrast to patient surveys, most physicians thought their patients understood why they had an ICD, were aware of the option of deactivation and wished to be involved in decisions about ICD deactivation. 24 Very little is known about the attitudes of non-US clinicians and non-hospital clinicians, such as general practitioners, towards ICD deactivation. 25 Ongoing work in the UK involving health professionals who manage people with end-stage heart failure has highlighted that non-cardiologists may not
Box 1 Health professionals lack knowledge/support/ resources General practitioners (GPs) lack knowledge about implantable cardioverter defibrillators (ICDs) and ICD deactivation: INTERVIEWER (to GP focus group): I wondered what your views would be about defibrillator conversations – what you think should be happening? GP: Jings! We don’t even talk to them about end of life. You guess that one. I have no experience of that whatsoever. Nor have I ever come across anyone that that has been an issue for that anyone else has had to have that discussion with. Ever. Clinicians lack resources to discuss ICD deactivation: We, all the staff, the nursing staff and myself found it very difficult to discuss with X and we discussed it over a matter of weeks and months. And we also found it difficult because X maybe wasn’t quite so realistic about his prognosis and we once explained the pacemaker part of his wouldn’t be switched off and that this was just a preventative thing to stop it firing and causing distress. After that he was maybe a bit happier because certainly at that point he felt he was suffering a bit in terms of his symptom control. It was a very difficult process. I must admit I didn’t feel I had an awful lot of written material. I felt I could have done with something to back up my information. And that’s maybe something for me to look into for the future but I felt I was kind of repeatedly discussing this with him and didn’t have an awful lot of information. I felt he wanted to read something or he wanted to know something and he just couldn’t grasp it so it took us maybe 2 or 3 months to discuss it through. Geriatrician. 96
understand ICDs and may feel unsupported in discussions about ICD deactivation (box 1).
WHAT DO PATIENTS AND CARERS THINK ABOUT DEACTIVATING ICDS? There are little published data about patient attitudes towards ICD deactivation. In a series of semistructured interviews, 15 ICD recipients from an electrophysiology clinic at a US academic medical centre were asked about ICD deactivation. Most patients were keen to talk about their ICD, but reluctant to engage in conversations about deactivation. This reluctance extended to discussing ICD deactivation with their physician; several patients thought that their physician should take such decisions. Patients displayed high levels of anxiety about future ICD shocks, particularly those patients who had previously received ICD shocks. Very few patients knew that the shock function of their ICD could be deactivated. Many patients had significant misconceptions about the function of their ICD, making it difficult to contribute to informed decisions about ICD deactivation.18 Ongoing work in the UK involving patients with end-stage heart failure has reinforced the concept that many patients do not understand their condition, their prognosis or the function of an ICD (box 2). These factors make it very difficult to discuss ICD deactivation. Recent research has cast doubt on the common assumption that older individuals with end-stage heart failure favour quality of life over longevity. Among 622 patients aged >60 years with chronic heart failure, 74% were not willing to trade survival time for improved quality of life and 51% wished to be resuscitated if necessary. 26 Awareness of such attitudes should be borne in mind during discussions about ICD deactivation. Although there are very little published data, ICD deactivation is also an extremely contentious issue for the carers of patients with end-stage heart failure. Carers of patients with end-stage heart failure may be distressed by the idea of ICD deactivation and may struggle to understand the rationale for ICD deactivation (box 3).
SUMMARY The prognostic benefit of an ICD is likely to attenuate with progression to end-stage heart failure. The risk of multiple futile ICD shocks before death is uncertain, but probably occurs in less than
Box 2 Patients have limited understanding about their condition Patients have limited understanding of their diagnosis: The left ventricle isn’t working properly. When I had the heart attack it damaged it a bit so that is what I was told, that is all I know. Female, age 72 Patients have limited understanding of their prognosis: I mean I’m not an expert but I’ve got an idea of what’s happening. I know what’s caused this, it doesn’t scare me. I mean if it was killing me, well it is, I suppose, but I just forget that bit. I don’t think I’m going to die next week. Male, age 67 Patients have limited understanding of implantable cardioverter defibrillator function: I have got a what do you call it fitted, a defibrillator which helps to keep you alive and the medicine that they will give me will hopefully monitor my heart system. But that is what they have told me. I am actually quite floored with it. Male, age 65 BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
Features
Box 3 Carer perspectives about implantable cardioverter defibrillator deactivation discussions And even last time I had said to her ‘why is death imminent?’, talking about switching off the defibrillator and when they do that. I mean I don’t think we need to even think about doing that because at the end of the day the worse thing that happens is it fires and fires and fires and you get a three minute response and somebody is here…., I don’t think we have to dwell on that and, you know, that sort of thing. I can understand them talking about whether you want to be resuscitated or not, I think that is quite straightforward. Carer And then he says the defibrillator, he didn’t say he was taking it out, he says he was going to switch off the resus button. And again I said to him and why are you doing that? And he says ‘because its mainly, it can be very distressing because if X takes a heart attack and it doesn’t bring him round it would keep going off and you would get into an awful state’ and all that and I said ‘well I’m quite willing to take that chance’ I said, so just I prefer you to leave the defib as it is. Carer 10% of patients. The futility of ICD therapy can only be decided by an individual patient with the support of their healthcare professionals. Patient opinions about the amount of additional life that is justified by an ICD shock may not match professional expectations. Despite consensus that ICD deactivation should be routinely discussed, this rarely occurs in clinical practice. It is likely that many patients with end-stage heart failure die without having the opportunity to discuss ICD deactivation. Uncertainty about when to initiate discussions and reluctance by both doctors and patients to confront death and dying contribute to this problem. Non-specialists may also lack knowledge or feel unsupported, making ICD deactivation discussions less likely or more challenging. However, the issue should be considered in the wider context of end of life care planning in a population with suboptimal understanding of their condition and prognosis. We need to know more about how patients, carers, medical and nursing professionals understand the problem of ICD deactivation. We need to study interventions that might assist in crossing the translational gap between current ideas about ‘best practice’ and the realities of end-stage heart failure. Acknowledgements This research is supported by the Caring Together programme http://www.mariecurie.org.uk/caringtogether a partnership programme by Marie Curie Cancer Care, British Heart Foundation Scotland and NHS Greater Glasgow and Clyde. Funding KH, FM, SB, UM and CRM have received funding from the Caring Together programme which is jointly funded by British Heart Foundation Scotland, Marie Curie Cancer Care and NHS Greater Glasgow and Clyde. SP is currently funded by an unrestricted educational grant from St Jude Medical. Competing interests None. Ethics approval Approval provided by the West of Scotland Research Ethics Service (10/S0701/20). Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005;112:e154–e235.
BMJ Supportive & Palliative Care 2012;2:94–97. doi:10.1136/bmjspcare-2011-000176
2. Kadish A, Dyer A, Daubert JP, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004;350:2151–2158. 3. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverterdefibrillator for congestive heart failure. N Engl J Med 2005;352:225–237. 4. Packer DL, Prutkin JM, Hellkamp AS, et al. Impact of implantable cardioverterdefibrillator, amiodarone, and placebo on the mode of death in stable patients with heart failure: analysis from the sudden cardiac death in heart failure trial. Circulation 2009;120:2170–2176. 5. Levy WC, Lee KL, Hellkamp AS, et al. Maximizing survival benefit with primary prevention implantable cardioverter-defibrillator therapy in a heart failure population. Circulation 2009;120:835–842. 6. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 2006;8:746–837. 7. Whang W, Mittleman MA, Rich DQ, et al. Heart failure and the risk of shocks in patients with implantable cardioverter defibrillators: results from the Triggers Of Ventricular Arrhythmias (TOVA) study. Circulation 2004;109:1386–1391. 8. Mozaffarian D, Anker SD, Anand I, et al. Prediction of mode of death in heart failure: the Seattle Heart Failure Model. Circulation 2007;116:392–398. 9. Goldenberg I, Moss AJ, Hall WJ, et al. Causes and consequences of heart failure after prophylactic implantation of a defibrillator in the multicenter automatic defibrillator implantation trial II. Circulation 2006;113:2810–2817. 10. Goldenberg I, Gillespie J, Moss AJ, et al. Long-term benefit of primary prevention with an implantable cardioverter-defibrillator: an extended 8-year follow-up study of the Multicenter Automatic Defibrillator Implantation Trial II. Circulation 2010;122:1265–1271. 11. Koller MT, Schaer B, Wolbers M, et al. Death without prior appropriate implantable cardioverter-defibrillator therapy: a competing risk study. Circulation 2008;117:1918–1926. 12. Theuns DA, Schaer BA, Soliman OI, et al. The prognosis of implantable defibrillator patients treated with cardiac resynchronization therapy: comorbidity burden as predictor of mortality. Europace 2011;13:62–69. 13. Lewis WR, Luebke DL, Johnson NJ, et al. Withdrawing implantable defibrillator shock therapy in terminally ill patients. Am J Med 2006;119:892–896. 14. Goldstein NE, Lampert R, Bradley E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med 2004;141: 835–838. 15. Beattie J. Implantable cardioverter defibrillators in patients who are reaching the end of life. London: British Heart Foundation, 2007. 16. Jaarsma T, Beattie JM, Ryder M, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009;11:433–443. 17. Lampert R, Hayes DL, Annas GJ, 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. 18. Goldstein NE, Mehta D, Siddiqui S, et al. ‘That’s like an act of suicide’ patients’ attitudes toward deactivation of implantable defibrillators. J Gen Intern Med 2008;23 Suppl 1:7–12. 19. Marinskis G, van Erven L; EHRA Scientific Initiatives Committee. Deactivation of implanted cardioverter-defibrillators at the end of life: results of the EHRA survey. Europace 2010;12:1176–1177. 20. Goldstein N, Carlson M, Livote E, et al. Brief communication: Management of implantable cardioverter-defibrillators in hospice: A nationwide survey. Ann Intern Med 2010;152:296–299. 21. Barclay S, Momen N, Case-Upton S, et al. End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis. Br J Gen Pract 2011;61:e49–e62. 22. Goldstein NE, Mehta D, Teitelbaum E, et al. “It’s like crossing a bridge” complexities preventing physicians from discussing deactivation of implantable defibrillators at the end of life. J Gen Intern Med 2008;23 Suppl 1:2–6. 23. Kramer DB, Kesselheim AS, Brock DW, et al. Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment. Heart Rhythm 2010;7:1537–1542. 24. Goldstein N, Bradley E, Zeidman J, et al. Barriers to conversations about deactivation of implantable defibrillators in seriously ill patients: results of a nationwide survey comparing cardiology specialists to primary care physicians. J Am Coll Cardiol 2009;54:371–373. 25. Russo JE. Deactivation of ICDs at the end of life: a systematic review of clinical practices and provider and patient attitudes. Am J Nurs 2011;111:26–35. 26. Brunner-La Rocca H-P, Rickenbacher P, Muzzarelli S, et al. End-of-life preferences of elderly patients with chronic heart failure. Eur Heart J 2012;33:752–759..
97
Downloaded from http://spcare.bmj.com/ on November 27, 2015 - Published by group.bmj.com
ICDs in end-stage heart failure Stephen J Pettit, Susan Browne, Karen J Hogg, Derek T Connelly, Roy S Gardner, Carl R May, Una Macleod and Frances S Mair BMJ Support Palliat Care 2012 2: 94-97
doi: 10.1136/bmjspcare-2011-000176 Updated information and services can be found at: http://spcare.bmj.com/content/2/2/94
These include:
References Email alerting service
This article cites 25 articles, 11 of which you can access for free at: http://spcare.bmj.com/content/2/2/94#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
