End-of-Life Care in Patients with Implantable Cardioverter Defibrillators: A MADIT-II Substudy
Dr. Zareba, Dr. Moss, and Dr. Daubert have received research grant from Boston Scientific Corp.
Conflict of interest: MADIT-II trial was supported by a research grant from Guidant (Boston Scientific Corp.) to the University of Rochester School of Medicine and Dentistry.
Address for reprints: Saadia Sherazi, M.D., MS Heart Research Follow-up Program Cardiology Division, University of Rochester Medical Center 265 Crittenden Blvd., Rochester, NY 14642. Fax: 585-273-5283; e-mail: email@example.com
Implantable cardioverter defibrillator (ICD)-delivered shocks can cause substantial distress, warranting consideration of ICD deactivation at end of life. This study was designed to describe the patterns of end-of-life management in patients with ICDs.
There was a retrospective chart review of 98 patients who died in the ICD arm of multicenter automated defibrillator implantation trial II (MADIT II). The pattern of ICD management and the frequency of ICD shocks delivered before death were reviewed.
We identified three groups: Group 1 consisting of individuals who underwent ICD, deactivation, 15 (15%); Group 2 patients without ICD deactivation who were in hospice or with “do not resuscitate” (DNR) orders, 36 (37%); and Group 3 patients without ICD deactivation who were not in hospice care and did not have DNR orders, 47 (48%). Out of 15 deactivations, 11 (73%) occurred in the week before death. None of the patients in Group 1 received an ICD shock in the 24-hour period before death. However, one (3%) patient from Group 2 and nine (19%) patients from Group 3 had shocks during the 24 hours before death (P = 0.03). In the last week before death, three (20%), two (6%), and six (13%) patients received ICD shocks in the three groups, respectively (P = 0.28).
In patients with terminal conditions who are at risk for imminent death, active management of the patient's ICD, including timely discussions regarding ICD deactivation, may reduce the risk of ICD shocks during the end of life.