Author + information
- Dilek Yilmaz, MD,
- Aafke C. van der Heijden, MD,
- Joep Thijssen, MD, PhD,
- Martin J. Schalij, MD, PhD and
- Lieselot van Erven, MD, PhD∗ ()
- ↵∗Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
Patients with an implantable cardioverter-defibrillator (ICD) are at risk of unnecessary painful shocks at the end of life when tachytherapy is still active. In 2010, the European Heart Rhythm Associations and the American Heart Rhythm Society published statements on ICD-therapy in patients nearing end of life (1,2). Subsequently, the Netherlands Association for Cardiology released the national guideline “ICD/pacemakers in the last phase of life” in 2013. The current study was performed to evaluate the practice of ICD tachytherapy deactivation before death over the past 10 years to reveal areas for improvement.
All patients who received an ICD or cardiac resynchronization therapy-defibrillator at our institution and who died between 2006 and 2015 were evaluated. Follow-up was recorded in electronic patient files and the survival status of patients was retrieved from municipal civil registries. Patient records were reviewed to identify cause of death, ICD therapy status, and type of device at time of death. Causes of death were categorized according to a modified Hinkle-Thaler Classification (3).
Between 2006 and 2015, 949 patients with an ICD died (mean age 72 ± 10 years; 734 [77%] males; 577 [61%] primary prevention; median time from first ICD 4.5 years [interquartile range: 2 to 7 years]). Baseline characteristics of patients withdrawn from tachytherapy before death did not differ from those who were not (data not shown). Overall, 321 (34%) devices were deactivated before death. A Kruskal-Wallis H test showed that the time from deactivation to death did not significantly differ between the years (p = 0.12), with time from deactivation ranging from 1 to 24 days. Time from deactivation was <24 h in 104 (34%) of the patients.
We observed a gradual increase in the proportion of patients withdrawn from tachytherapy over time to just >50% in the past 3 years (Figure 1). A logistic regression analysis was performed to evaluate the differences in tachytherapy withdrawal rates over the years, which was statistically significant (p < 0.0001). Moreover, the rate of withdrawal doubled within the first 4 years. Most frequently, tachytherapy deactivation was initiated by the attending physicians in the hospital (n = 197 [61%]), most often while the patient was in a hospitalized setting (n = 177 [55%]). The most frequent causes of death observed in the 321 patients withdrawn from tachytherapy were terminal heart failure in 38% and malignancy in 24%. Other causes included infectious diseases, renal failure, and stroke. This study provides insight into the practice of tachytherapy withdrawal during the last phase of life in a large population of patients with ICDs throughout the past decade. The gradual increase of tachytherapy deactivation over the past 10 years from 6% to 52% is encouraging. Nevertheless, a substantial proportion of patients remain at risk for shocks. In addition, time from deactivation to death has not changed over the years. This allows for the question of how further improvement can be achieved. To evaluate whether patients in the past 3 years had an identifiable terminal stage that could have prompted discussions on tachytherapy withdrawal, all cases of the plateau era were reviewed. Between 2013 and 2015, 141 patients died without prior tachytherapy withdrawal. In retrospect, a terminal stage could be identified in 36 (26%). In 2 of these patients, tachytherapy withdrawal was planned but could not be performed in time. Acute deterioration of a patient’s clinical status appears to prompt ICD deactivation. However, the limited time remaining and the subsequent logistical constraints lead to failure of withdrawal. Most important, additional improvement is to be expected from recognizing the beginning of the palliative or terminal phase. This stage is easily missed at the biannual (or less frequent in cases of remote monitoring) checkups by ICD caregivers. Early and repetitive discussions (e.g., at first implantation or regular ICD follow-ups) with the patient and family on the risks of shocks at the end of life is needed to allow for time to create patient awareness and acceptance of ICD therapy withdrawal.
Please note: The Department of Cardiology at Leiden University Medical Center has received unrestricted research grants from Biotronik, Boston Scientific, Medtronic, and Edwards Lifesciences. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation