A potential barrier to discussing deactivation of implantable cardioverter defibrillators was patients' lack of knowledge

Cardiac sympathetic denervation and mental health

BACKGROUND

Bilateral cardiac sympathetic denervation (BCSD) is a surgical treatment for refractory ventricular arrhythmias. Although the procedure has shown efficacy at reducing cardiac arrhythmias, its impact on mental health is unknown. In the current study we examined associations between the BCSD procedure and mental health.

METHODS

10 ventricular arrhythmia patients undergoing BCSD completed assessments of anxiety, depression, and posttraumatic stress symptoms at pre- and post-BCSD time points. Wilcoxon signed rank and Mann-Whitney U tests were used to examine differences in mental health symptoms in the pre- and post-BSCD states. Point biserial correlations were used to explore associations between BCSD response and mental health symptoms.

RESULTS

A significant reduction of anxiety symptoms was observed from pre- to post-BCSD. At the post-BCSD assessment, participants who successfully responded to the BCSD procedure exhibited lower anxiety symptoms compared to non-responders. However, no significant relationships were identified for depressive or PTSD symptoms.

CONCLUSION

The BCSD procedure is associated with reduced anxiety shortly after successful treatment for refractory ventricular arrhythmias in a small sample. Longitudinal surveillance of mental health symptoms after BCSD may be warranted to monitor the impact of this procedure on mental health.

Patients’ Perspectives on End-Of-Life Issues and Implantable Cardioverter Defibrillators

Increasing numbers of cardiovascular patients are receiving implantable cardioverter defibrillators (ICDs) for primary prevention of sudden cardiac death (SCD). This report examines patients’ perspectives on related end-of-life issues. Using a grounded theory approach, audiotaped, semi-structured interviews were undertaken with 30 participants from two ICD referral centres in southwestern Ontario (24 who accepted an ICD and 6 who declined). Interview transcripts, verification with interviewees, researcher memos, published literature, and participant demographics were analyzed using NVivo7. Most participants were male, had comorbidities and an ejection fraction of less than 30 percent, and ranged in age from 26 to 87. Consensus was reached by three research team members on three main themes: quality versus quantity of life, preferred mode of death, and the technical realities of the ICD. The ICD was considered in relation to both quantity and quality of life. Most participants focused on the prevention of SCD, not the implications of the ICD for death by any other cause. Participants advocated for incorporating the ICD into advance care planning. Our findings have implications for the development of advance care plans and education of health professionals.

Original research: deactivation of ICDs at the end of life: a systematic review of clinical practices and provider and patient attitudes

BACKGROUND

The implantable cardioverter-defibrillator (ICD) has become a standard treatment for people at risk for life-threatening cardiac arrhythmias. To restore normal heart rhythm, the ICD delivers a high-energy, painful electrical shock. Because the device is so effective in treating sudden cardiac arrest, people with ICDs are more likely to die from other causes. But their deaths can be needlessly painful if the ICD delivers shocks during the active phase of dying. Although device deactivation is an option, no formal practice protocols address this, and advance planning discussions don't often include potential ICD deactivation.

OBJECTIVE

The purpose of this systematic review was twofold: to identify factors that delay ICD deactivation discussions and to identify ways to promote timely deactivation discussions and thus foster better patient-centered, end-of-life care for people with ICDs.

METHODS

Using relevant search terms, a literature search for articles on the topics of interest was performed in multiple databases. The search was limited to articles published in English in peer-reviewed journals between January 1, 1999, and October 31, 2010. Reference lists of applicable articles were also examined for any additional relevant studies. After applying inclusion and exclusion criteria, 14 studies investigating the topics of interest were identified and are included in this review.

FINDINGS

Providers' knowledge deficits about ICD functions and attitudes about ICD deactivation in terminally ill patients can adversely affect the timing of deactivation discussions. Providers' reluctance to discuss deactivation may stem in part from personal discomfort and lack of experience with this option. ICDs may be viewed differently from other life-sustaining measures. Providers may also feel ill prepared to initiate a discussion about deactivation with patients; some might prefer expert guidance or that others initiate such discussion. There's evidence that ICD deactivation is most often performed by an industry representative, and that continuity of care is lost. Although there's been scant research on patient attitudes about ICD deactivation, it appears that patients lack sufficient knowledge of ICD function to make informed decisions about deactivation. A complex psychological relationship may exist between patients and their ICDs. Deactivation discussions occur more frequently when a formal institutional policy exists. ICD deactivation in terminally ill patients is more likely when deactivation is discussed as part of an interdisciplinary approach to care.

CONCLUSIONS

Both patients and providers need better knowledge of ICD functions and options at the end of life in order to foster more timely discussion of device deactivation. More research is needed, in particular regarding patient attitudes toward ICD deactivation. Formal ICD deactivation policies should be developed to guide providers. A comprehensive and interdisciplinary approach to deactivation discussions should be considered.

KEYWORDS

cardiac arrhythmia, cardiac implantable electronic device, deactivation, defibrillation, end-of-life care, heart failure, hospice care, implantable cardioverter-defibrillator, palliative care, ventricular tachyarrhythmia.