Adverse Experiences With Implantable Defibrillators in Oregon Hospices

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) improve survival in patients at risk for recurrent, sustained ventricular tachycardia or fibrillation. Unless deactivated, ICDs may deliver unwanted shocks to terminally ill patients near the time of death. This study sought to determine the frequency and nature of adverse experiences with ICDs events and what preventative measures the hospice programs had taken. METHOD: A mailed survey to all 50 Oregon Hospice Programs in August 2008. RESULTS: 42/50 (84%) programs participated. 36/42 (86%) programs reported having taken care of a patient with an ICD in the preceding four years. The average number of patients with ICDs per program increased from 2.2 (SD 2.5) in 2005 & 2006 to 3.6 (SD 3.7) in 2007 & 2008. Of the 36 programs who had cared for a patient with an ICD, 31 (86%) reported having some kind of adverse experience. These ranged from unwanted shocks delivered (64%), patient/ family distress related to the decision to deactivate the ICD (47%), and time delay in ICD deactivation (42%). Only 16 (38%) programs had policies for managing ICDs and only 19 (43%) routinely screened new patients for ICDs. DISCUSSION: As patients near the end of their lives, receiving defibrillating shocks may no longer be consistent with their goals of care. Based on the high frequencies of potentially preventable adverse outcomes documented by this study, we propose that hospices routinely screen patients for ICDs and adopt policies to proactively manage them, rather than in response to an adverse event