Defibrillation deactivation state and activation status in patients with implantable cardioverter-defibrillators at the end of life

Abstract Background Implantable cardioverter-defibrillators (ICDs) are effective in preventing sudden cardiac death due to lethal arrhythmias. Defibrillation is also known to cause physical and emotional distress to patients, and guidelines on palliative care for cardiovascular disease recommend that when patients with ICDs reach the end of life, the benefits and burdens of ICDs should be fully explained to patients and a policy regarding the cessation of defibrillation discussed. However, there are few reports on the treatment status and defibrillation deactivation in patients with ICDs in the terminal phase. Aim To investigate defibrillation activation and defibrillation deactivation in terminally ill patients with ICDs. Results Death was confirmed in 146 patients in the medical record, and a DNAR policy was decided in 46 patients. The decision to deactivate defibrillation was informed to 24 patients (16%), and 15 patients (10%) were deactivated (11 patients in terminal heart failure and 4 patients in others). Four of the nine patients (6%) who did not deactivate defibrillation had a shock before death.Of the 22 patients (14 cardiovascular deaths and 8 others) who were not explained about the deactivation of defibrillation, 4 had shock activation before death.Of the 24 patients who received explanation about defibrillation deactivation, 6 (25%) had the policy decided by the patient and family, and 18 (75%) had the policy decided by the family because the patient's will could not be confirmed due to deterioration of end-stage condition. Discussion This study showed that defibrillation was deactivated in only 10% of Japanese patients with end-stage ICDs.ICD patients do not always reach the end of life due to heart failure. It is important for physicians, clinical engineers, and device nurses involved in device care to provide information and to confirm the wishes of patients and their families regarding the deactivation of defibrillation so that they can be supported in their decision-making regarding defibrillation no matter under what circumstances they reach the end of life. Conclusion Discussion of ICD deactivation in palliative care is needed to reduce the risk of painful shock and distress at the end of life.