Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records

BACKGROUND

The implantable cardioverter defibrillator (ICD) might give unwanted shocks in the last month of life. Guidelines recommend deactivation of the ICD prior to death.

AIMS

The aims of this study were to examine trends in time (2007-2016) in how and when decisions are made about ICD deactivation, and to examine patient- and disease-related factors which may have influenced these decisions. In addition, care and ICD shock frequency in the last month of life of ICD patients are described.

METHODS

Medical records of a sample of deceased patients who had their ICD implanted in 1999-2015 in a Dutch university (n = 308) or general (n = 72) hospital were examined.

RESULTS

Median age at death was 71 years, and 88% were male. ICD deactivation discussions increased from 6% for patients who had died between 2007 and 2009 to 35% for patients who had died between 2013 and 2016. ICD deactivation rates increased in these periods from 16% to 42%. Presence of do-not-resuscitate (DNR) orders increased from 9% to 46%. Palliative care consultations increased from 0% to 9%. When the ICD remained active, shocks were reported for 7% of patients in the last month of life. Predictors of ICD deactivation were the occurrence of ICD deactivation discussions after implantation (OR 69.30, CI 26.45-181.59), DNR order (OR 6.83, CI 4.19-11.12), do-not-intubate order (OR 6.41, CI 3.75-10.96), and palliative care consultations (OR 8.67, CI 2.76-27.21).

CONCLUSION

ICD deactivation discussions and deactivation rates have increased since 2007. Nevertheless, ICDs remain active in the majority of patients at the end of life, some of whom experience shocks.