Disabling shock function on ICDs rarely done towards end of life

Despite the need for it towards the end of life, reprogramming implantable cardioverter defibrillators (ICDs) to disable the shock function appears to be rarely performed, according to a recent study.

“In these meta-analyses, including data from six different developed countries, we found a low device-reprogramming rate and a very low rate of advance directives explicitly mentioning the device,” researchers said.

Fourteen studies were retrieved and deemed eligible for meta-analysis, majority of which were retrospective cohort studies. Seven of these studies quantitatively reported on the prevalence of device reprogramming at the end of life and found that the shock function was disabled in only 28 percent of the cases. [Palliat Med 2020;doi:10.1177/0269216320929548]

Researchers observed some heterogeneity of the data around the publication of the Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA) pertaining to the reprogramming of the ICD. The guidelines were published in 2010.

Five studies enrolled participants who received treatment before 2010, which saw a device reprogramming prevalence rate of 20 percent. In comparison, the pooled ICD reprogramming rate in patients after 2010 was 40 percent.

“This study shows an improvement in the rates of implantable cardioverter defibrillator reprogramming at the end of life after the publication of a consensus statement as the ones from the HRS and EHRA,” the researchers said.

Despite this improvement, the explicit discussion of what to do with the implant was rarely included in advanced directives, assessed in six studies. The pooled prevalence of having any advanced directive was 53 percent; the lowest rate across the included reports was 30 percent.

However, the rate of advanced directives that addressed the ICD was much lower. Pooled analysis of five studies yielded a prevalence rate of 1 percent, with a peak of 2.1 percent.

“This is very low for any cutoff of percentage indicating a satisfactory use of advance directive and indicates that the advance directive, which was created to increase patients’ autonomy and ensure medical management that aligns with their preferences, is an underused legal document,” the researchers said.

Advanced directives pertain to written documents that detail actions and procedures a patient sanctions once they become incapacitated towards the end of life. In the present study, this definition included wills and designating representative to make medical decisions.

“Although implantable cardioverter defibrillator is a successful therapy, all patients eventually progress to the end-of-life phase,” researchers said. “In patients with a progressive and marked decline, the shock function of the implantable cardioverter defibrillator no longer prolongs life and may instead cause them and their families unnecessary distress.”

The present study uncovers low rates of disabling the shock function on these devices and highlights “the importance of more physicians and other health professionals adhering to clinical guidelines in discussing with the patient their preferences regarding the management of the implantable cardioverter defibrillator at the end of life and in documenting them.”