Author + information
- Claire Raphael, MA, BSc* (, )
- Prapa Kanagaratnam, PhD and
- Darrel P. Francis, MA
- ↵*International Centre for Circulatory Health, Imperial College and St. Mary's Hospital, 59-61 North Wharf Road, London W2 1LA, United Kingdom
We read the recent report by Goldstein et al. (1) with interest. Their study polled 147 doctors who looked after patients with implantable cardioverter-defibrillators (ICDs) regarding perceived barriers to end-of-life discussions with these patients. Although it illustrates that doctors have a high degree of confidence in their skills in end-of-life discussions with ICD patients, we believe that doctors may in general be substantially overestimating patients' level of understanding of the device.
In the report by Goldstein et al. (1), for instance, 93% of the cardiologists believed that their patients understood why they had an ICD. Most clinicians also believed that patients knew the ICD could be deactivated. Our own data, which is from the patient perspective, suggests a far poorer understanding of their ICDs. We performed a study of 54 patients (mean age 68 years, 79% men) with an ICD in situ for chronic heart failure. None had a combined device for biventricular pacing.
Patients had a generally disappointing understanding of the device. Only 38% of patients were aware that the device could be deactivated without being explanted. Only 65% of patients felt they understood the device as well as they would like to in order to make decisions. In fact, although 85% of patients understood that the device administered a shock, only 65% of patients understood that function of the device was solely to prevent sudden cardiac death rather than to improve symptoms.
Toward the end of the life of a patient with heart failure, the device can deliver painful and frightening shocks. Timely consideration and discussion of deactivation may allow this period to be more peaceful and natural.
However, if the patient does not understand how the device works, and the doctor does not realize that the patient does not understand, how can such a discussion be effective?
- American College of Cardiology Foundation
- Goldstein N.,
- Bradley E.,
- Zeidman J.,
- Mehta D.,
- Morrison R.S.