Clinician attitudes regarding ICD deactivation in DNR/DNI patients

Overall, our major findings were (1) residents, who provide much of the clinical care in a teaching hospital, are remarkably uncomfortable discussing ICD deactivation, (2) general internists and residents ask about ICD deactivation infrequently compared to geriatricians and cardiologists, and (3) about one fifth of our respondents believe ICD deactivation is automatically part of a DNR/DNI order.

Although the majority of respondents did not routinely address ICD deactivation in conjunction with code status, there was significant variability among subgroups. For example, 83.3% of geriatricians routinely discussed ICD deactivation as part of code status compared with only 4% of first-year residents and 10.5% of inpatient general internists. This finding is interesting because 90.7% of all respondents believed that discussions of code status should address preferences on ICD deactivation. This apparent discrepancy could be explained by the relatively small number of patients admitted to the hospital who have both an ICD and a request to be DNR/DNI. Residents and inpatient general internists see a very broad spectrum of patients; ICD deactivation is frequently irrelevant in the cases these physicians manage. The subset of patients seen in consultation by cardiologists and geriatricians, by contrast, is expected to include a larger proportion of patients with ICDs. Therefore, discussing ICD deactivation will be more relevant to their daily practice. Fear of alienating patients was not a reason for our findings, as our respondents did not express concern that recommending ICD deactivation would harm the patient-clinician relationship.

There are several possible reasons that residents, particularly interns, are uncomfortable discussing ICD deactivation. A lack of exposure to ICD deactivation is probably a key contributor. Over half of interns had never been involved in any ICD deactivations. Residents and hospitalists may also feel as if they are overstepping their boundaries to discuss deactivating ICD therapies. Their feelings may not be misplaced, as one survey of ICD patients found that over 75% thought responsibility for discussing ICD deactivation, at least at the end of life, rests with cardiologists or electrophysiologists.⁶

The HRS guidelines call for individualized decisions regarding ICD deactivation, even if a patient is DNR/DNI. However, our respondents frequently felt a standardized approach was indicated, with 21% believing that a DNR/DNI order included ICD deactivation. Additionally, 28% agreed that even non-terminally ill DNR/DNI patients should have their device deactivated. This is relevant because it is the role of clinicians to engage in shared decision-making with their patients. If the clinician holds the fixed belief that a DNR/DNI order, regardless of the precise clinical scenario, should include ICD deactivation, they may pressure a patient to have their device deactivated even if it could still benefit them.

In 2009, Kelley et al published results of a survey on ICD deactivation at the end of life.⁹ They contacted 4,876 attending physicians in cardiology, electrophysiology, geriatrics, and general medicine, receiving 558 responses. The survey included Likert-scale questions assessing attitudes and knowledge about ICD functionality. Demographic information was also collected, including how many patients in their practice had ICDs and how often they had previously discussed ICD deactivation.

There are some interesting comparisons between Kelley et al’s findings and ours, although we included trainees and the precise wording of questions was different. The specific questions used by Kelley et al to ask whether ICD shocks were painful or distressing and to ask if ICD deactivation is part of a DNR order were: “The shock from an ICD is very painful for most patients.” “The shock of an ICD at the end of life is distressing to a patient and their loved ones.” “A DNR order is equivalent to deactivation of an ICD.”

Only 47% of general internists in the Kelley et al survey thought that ICD shocks were painful, compared with 83% of electrophysiologists. In addition, 65% of general internists and 85% of electrophysiologists viewed shocks at the end of life to be distressing to patients and families. By contrast, our respondents were nearly unanimous in believing shocks to be painful and distressing. This discrepancy may be due to the growing prevalence of ICDs over the past several years as well as the growing body of literature on unnecessary shocks at the end of life. In line with our study, 19% of their respondents believed a DNR order was equivalent to ICD deactivation.⁹

Taken together, our findings indicate that additional education for clinicians of all levels could be helpful. Didactic lessons cannot replace experience, and it is important for residents to be exposed to discussions of ICD deactivation. However, lessons about ICD therapies and practical examples of how to broach the topic of deactivation could be beneficial, especially for interns whose responsibility includes discussions of code status. Within the context of an internal medicine residency, the fundamentals of ICD functionality could be covered during rotations on cardiology or palliative care services. Additionally, the recommendations of the HRS for device management can be covered in didactic sessions. Similar opportunities could be built into continuing medical education for practicing physicians and the training of advanced practice providers.

There are limitations to this survey, most notably the fact that it was restricted to a single academic medical center, the patient population and practices of which may not be generalizable to medical practice at large. Selection bias is also a distinct possibility given the 32% overall response rate; those who responded may feel more strongly about the survey topic. Our study subgroups may have interpreted questions differently because of their particular area of clinical practice. The small sample size also precluded an effective analysis of fellows and advanced practice practitioners due to lack of power. A major strength of this survey was the inclusion of a large number of residents upon whom the majority of inpatient contact rests. Future work could include expanding the survey to multiple medical centers, which would enhance generalizability and improve the ability to recruit sufficient fellows and advanced practice providers.