Clinician Attitudes Regarding ICD Deactivation in DNR/DNI Patients
Implantable cardioverter-defibrillators (ICDs) offer lifesaving therapies but can become burdensome at the end of life. Many ICD patients choose to implement a do-not-resuscitate/do-not-intubate (DNR/DNI) order. When hospitalized, patients are seen by a range of clinicians whose beliefs about ICD management in DNR/DNI patients may vary.OBJECTIVE:
To assess clinician opinions on managing ICDs in DNR/DNI patients and stratify it by specialty and training level.METHODS:
An online survey was sent to attending physicians, fellows, advanced practice providers (physician assistants and nurse practitioners), and residents in general internal medicine, cardiology, electrophysiology, and geriatrics at an academic medical center. Residents were compared to attending physicians, and attending physicians were additionally stratified by specialty.RESULTS:
The response rate was 32%, yielding 161 complete responses. Among residents (n = 73), 49.3% were comfortable with discussing ICD deactivation and 16.4% asked about it routinely. By contrast, among attending physicians (n = 66), 78.8% were comfortable with discussing deactivation and 34.8% routinely asked. Fewer general internists (19.2% of inpatient internists, 10.5% of outpatient internists) routinely asked about ICD deactivation as compared with 83.3% of geriatricians and 73.3% of cardiologists/electrophysiologists. Twenty-one percent of all respondents felt a DNR/DNI order equated to requesting ICD deactivation; Heart Rhythm Society (HRS) guidelines favor a more nuanced approach.CONCLUSIONS:
Residents are less comfortable discussing ICD deactivation than attending physicians and do so less frequently. General internists discuss deactivation less routinely than cardiologists and geriatricians. Many providers hold opinions about ICD deactivation that differ from HRS guidelines. Additional didactic education could help close these gaps in clinician practice.