53 Please dont shock me: a qi project on implantable cardioverter defibrillators (icds) at the end of life care & dnar

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Abstract

Introduction

There is an increase in Implantable Cardioverter Defibrillators (ICDs) and Cardiac Resynchronization Therapy Defibrillators (CRT-Ds) being implanted every year. With patients living longer, the number of patients reaching the end of life with an active ICD or CRT-D is also on the rise. These can be missed or be mistaken for a pacemaker, especially during the end of life care.

Problem

In 2015, at our hospital, 75% of patients with an ICD/CRT-D who died had no deactivation. Some of these patients did receive painful and undesirable shocks from their active ICD/CRT-D upon death; unfortunately witnessed by some of their worried families. The hospital staff were surveyed about the awareness on ICDs/CRT-Ds at the end of life and upon death, which revealed>60% of staff were unaware what to do.

Aims/Methodology

A QI project was established to increase the number of ICD/CRT-D deactivation discussions and switch offs during the end of life care by 50%, over a 6 month period. Since January 2016, there were different interventions every month; including Grand round, departmental teaching, posters (Figure 1), implementing related questions in the palliative pathway and e-messages.

Results

After 4 months, 66% of patients with an active ICD/CRT-D received discussions and switch-offs in advance with good timing before death (Figure 2). In turn, there was a strong impact on patient-centred care, quality and co-ordinated care, efficiency, effectiveness, cost and patient safety.

Conclusions

ICDs/CRT-Ds can save lives. However, patients reaching the end of life should be put at ease and comfort by discussing ICD/CRT-D deactivation at DNAR (’Do Not Attempt Resuscitation’) discussion and have their ICD/CRT-D switched off in advance with good timing.

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