Nathan E. Goldstein, MD; Melissa Carlson, MBA, PhD; Jean S. Kutner, MD, MSPH
Potential Conflicts of Interest: None disclosed.
Goldstein N., Carlson M., Kutner J.; Complexities of Defibrillator Deactivation. Ann Intern Med. 2010;153:134. doi: 10.7326/0003-4819-153-2-201007200-00018
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Published: Ann Intern Med. 2010;153(2):134.
We appreciate Drs. Dev and Galanos's thoughtful response to our article. The goal of our work has always been to encourage patient–clinician communication about ICD deactivation to ensure that patients and families can make informed choices that are consistent with their values and desires for care. As such, we do not suggest requiring deactivation of devices in all patients and encourage physicians to respect patient autonomy when it comes to ICD management—even if, in the clinician's mind, the patient's decision seems to be counterintuitive. Drs. Dev and Galanos's comments about patients not always deciding to deactivate an ICD are in line with our clinical experiences and other published data. Specifically, in our article in Annals several years ago (1), we found that only 21 of the 27 patients (78%) with an ICD who were reported to have had a previous conversation about device deactivation chose to deactivate the shocking function. Patients often have had their defibrillators for several years and may develop complex psychological relationships with respect to the device (2, 3). As 1 person with an ICD stated in our focus group: “All I know is that it is there to help me and as long as I don't do wrong by it, it won't do wrong by shocking me” (4). When describing the percentage of patients with heart failure who are discharged from hospice alive, Drs. Dev and Galanos's response shows that the course of patients with end-stage heart disease can be particularly difficult to predict (5). The experience of patients with heart failure underscores the importance of our recommendation that conversations should occur earlier in the course of a patient's illness, so that the patient and their caregivers can begin discussions and determine whether and when in the future the patient might want the device deactivated. These conversations will make decisions easier for the family if they find themselves in an emergency situation in which the patient is being shocked repeatedly at the end of life (1). Only by enabling early and comprehensive communication about ICD management in the context of other discussions about the patient's overall goals of care can we ensure the best quality of life and care for patients with advanced heart disease and for their families.
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