Clinician attitudes regarding ICD deactivation in DNR/DNI patients

Case-based and Likert-scale questions were considered for this survey, with the latter being chosen for ease of completion by respondents. An online survey tool (SurveyMonkey; San Mateo, CA) was used for data collection; no identifying data were collected. E-mail invitations to participate were sent to a combination of mailing lists and individual addresses for residents, fellows, advanced practice providers, and attending physicians in general internal medicine, cardiology, electrophysiology, and geriatrics. The survey remained open for 2.5 weeks. It was conducted 5 months into the academic year, thus trainees were well-established in their current roles. Two $25 gift cards were offered to respondents who entered their e-mail into a drawing; responses were not tied to e-mail addresses. Approval for the study was obtained from the University of Michigan Institutional Review Board.

The survey posed 12 questions assessing general attitudes about ICDs as well as individual beliefs and behaviors relating to ICD deactivation. Answers were on a Likert scale of 1 to 5 with 1 representing “strongly disagree” and 5 representing “strongly agree.” A score of 3 indicated “unsure or neutral.” The first 3 questions appeared together on the first page and were prefaced with “Please respond to the following statements about ICD shocks.” The next 9 were likewise grouped on the next page and were prefaced with “Please respond to the following statements about ICD deactivation.” All 12 questions are shown in Figures 1 and 2. Respondents could easily return to previous questions and change their answers. The survey ended with a third page showing 3 multiple choice demographic questions. The demographic questions were about clinical role (first-, second-, third-, or fourth-year resident, fellow, advanced practice provider, and attending), specialty, and number of ICD deactivations the respondent had been directly involved in (0, 1 to 5, 5 to 10, and more than 10). Specialty options were internal medicine resident, inpatient general medicine, outpatient general medicine, cardiology, electrophysiology, and geriatrics.

Likert scale answers of “agree” or “strongly agree” were grouped together as an affirmative response, while all other answers were grouped together as a nonaffirmative response. For analysis, residents were grouped together and their responses compared with attending physicians as a group. Additional analysis was done comparing attending physicians stratified by clinical specialty. Given the small number of responses from attending electrophysiologists, they were grouped with attending cardiologists for analysis. Due to the limited number of fellows and advanced practice providers who responded, further evaluation of these groups was not performed. Finally, the number of ICD deactivations respondents had been involved in was stratified by training level. All comparisons were performed using the two-tailed Pearson’s chi-squared test.

A total of 170 responses were collected from 508 individuals on the e-mail lists. Two responses were from registered nurses who were not part of the intended study sample and 7 responses were incomplete, having only answered the first 3 questions. These 9 responses were excluded from further analysis, yielding an overall response rate of 32%. The demographics of the remaining 161 respondents are shown in Table 1. Figure 1 shows overall responses to each question.

When comparing residents to attending physicians, there were no statistically significant between-differences except on questions 5 and 6. Specifically, residents were less comfortable than attending physicians discussing ICD deactivation and did so with less regularity (P < .001 and P = .018, respectively; Figure 2). Comfort levels improved markedly with experience: 29.2% of interns expressed comfort asking about ICD deactivation as compared with 60.7% of third- and-fourth year residents and 78.8% of attending physicians. Furthermore, comfort level seemed to parallel the regularity with which respondents asked about ICD deactivation: 4.2% of interns routinely asked about ICD deactivation as compared with 21.4% of third- and fourth-year residents and 34.8% of attending physicians.

There were no differences between groups when asked whether ICD deactivation was part of a DNR/DNI order (question 8), or if an ICD should be deactivated in DNR/DNI patients (questions 9 and 10). As shown in Figure 1, 21.1% of respondents felt that a DNR/DNI order is equivalent to requesting ICD deactivation, 60.2% felt that terminally ill DNR/DNI patients should have their device deactivated, and 28% felt that non-terminally ill DNR/DNI patients should have their device deactivated.