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Murray SC, McNamara C, Chatzi AV. The difficult discussion on the deactivation of implantable cardioverter devices at the end of life: a systematic review. ESC Heart Fail 2024. [PMID: 38741255 DOI: 10.1002/ehf2.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Implantable cardioverter defibrillators (ICDs) reliably prevent death due to life-threatening arrhythmias; this may become less relevant in people with more severe heart failure who are reaching the end of life (EOL). This review aimed to explore the ICD deactivation process and identify ethical issues, especially around the initiation of relevant discussions among professionals and patients. Available literature was reviewed using four electronic databases to identify issues that may deter healthcare professionals from having important deactivation discussions and to address considerations for ICD management prior to the EOL. The search resulted in the retainment of 12 studies. Three themes emerged from the data: barriers and facilitators, ethical considerations in clinical practice, and nurse's role. Lack of knowledge, which has been associated with cultural differences, has been found among the barriers, and interdisciplinary education and open communication appeared as facilitators. As clinicians' ethical considerations and fears emerged from the literature, nurses' special role has not been sufficiently supported. Complex care requires facilitation by multidisciplinary teams and education around the device's function regarding EOL issues. Establishing expert consensus statements on advance care planning might help define the distinct roles of each healthcare practitioner involved. Further research is needed in addressing the identified gaps.
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Affiliation(s)
- Siobhan C Murray
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Claire McNamara
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Anna V Chatzi
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
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Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024:S0012-3692(24)00153-3. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
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Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
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Landry-Hould F, Mondésert B, Day AG, Ross HJ, Brouillette J, Clarke B, Zieroth S, Toma M, Parent MC, Fowler RA, You JJ, Ducharme A. Characteristics of Clinicians Are Associated With Their Beliefs About ICD Deactivation: Insight From the DECIDE-HF Study. CJC Open 2021; 3:994-1001. [PMID: 34505038 PMCID: PMC8413241 DOI: 10.1016/j.cjco.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022] Open
Abstract
Background Discussing goals of care with heart failure patients is recommended but is not done systematically, due to factors such as time and personal beliefs. A recent survey showed that one-fifth of clinicians believe that implantable cardioverter defibrillator deactivation (ICDD) is unethical or constitutes physician-assisted suicide. We investigated whether individuals’ characteristics are associated with these beliefs. Methods The Decision-Making About Goals of Care for Hospitalized Patients With Heart Failure (DECIDE-HF) survey was given to healthcare providers at 9 hospitals to assess their perceived barriers to goals-of-care discussions. The association between respondent characteristics and their beliefs was examined using 2 adjusted logistic regression models. Results We included 760 clinicians (459 nurses, 94 fellows, and 207 cardiologists). The responses varied among professions, with the belief that ICDD is unethical considered to be important barrier by nurses (24%), fellows (10%), and staff (7%); P < 0.001). After adjusting for site, spirituality being more important in life (odds ratio [OR]: 2.21; 95% confidence interval [CI]:1.37-3.56; P = 0.001, compared to less important), region of training (Asia [OR: 5.88; 95% CI: 2.12-16.31; P = 0.001] and Middle East [OR: 5.55; 95% CI:1.57-19.63; P = 0.008] compared to Canada), and years in practice (OR: 1.32; 95% CI: 1.07-1.63; P = 0.01 per decade) influenced beliefs about ICDD being unethical, with similar results for the belief that ICDD represents physician-assisted suicide. Conclusions Sociocultural factors, region of training, and profession influence clinicians’ beliefs about ICDD being unethical and representing physician-assisted suicide. These factors and beliefs must be acknowledged when facing the delicate issue of end-of-life discussion.
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Affiliation(s)
- Florence Landry-Hould
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Blandine Mondésert
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Heather J Ross
- Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Brouillette
- Departments of Psychiatry and Addictology, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Brian Clarke
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shelley Zieroth
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mustafa Toma
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marie-Claude Parent
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Robert A Fowler
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John J You
- Department of Medicine, Division of General Internal and Hospitalist Medicine, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
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