Advance care planning and the management of implantable cardioverter defibrillators at the end of life.

Abstract

Heart failure (HF) due to left ventricular systolic dysfunction is a burgeoning epidemic with about 25 million cases worldwide. Over the past 20 years there have been major advances in our understanding of the pathophysiology of this condition with development of evidence based pharmacological, surgical and device therapies. HF patients are prone to lethal tachyarrhythmias, and the use of implantable cardioverter defibrillators (ICDs) to monitor and treat this hazard has increased exponentially. Many patients now receive ICDs as standalone devices, or combined with cardiac resynchronisation therapy (CRT-D). Despite our best therapeutic efforts, HF tends to progress inexorably. The activity of these devices, especially defibrillation shocks, can discomfort those dying of HF or an unrelated comorbidity. Advance care planning (ACP) is poorly utilised in HF care, but recent guidelines from the US and Europe have suggested that ACP should be central to the handling of such devices at the end of life. Implementing such policies may be challenging. Previous studies have demonstrated that both device recipients and physicians may be reluctant to broach the issue of ICD deactivation, and some healthcare professionals are uncertain about the ethical framework and legal implications. Significant clinical dilemmas may arise. In this workshop the authors will: outline the background to these concerns, describe the clinical features of advanced HF when ICD deactivation should be considered, present recent, published data from ICD patients on end of life device management and discuss the practicalities of ACP relevant to the affected population across a range of clinical settings.