Credit: Original article published here.
The implantable cardioverter defibrillator (ICD) is frequently utilized in patients with heart failure for primary and secondary prevention and treatment of unstable arrhythmias. This device is a unique medical intervention that may improve survival for select patients but does not necessarily improve quality of life and may even lead to detrimental impacts.
At the 2023 Houston Shock Symposium, Dr. Haider Warraich – director of the heart failure program at VA Boston Healthcare, assistant professor at Brigham and Women’s Hospital and prolific author highlighted the psychological stress that can impact ICD recipients and the physician role in addressing these stressors with our patients.
Psychological stressors can present in many ways in ICD recipients; ranging from feeling phantom shocks to avoiding engagements due to fear of shock and persistent hyper-vigilance. Identified risk factors for increased psychosocial distress in ICD recipients include younger age less than 50 years old, female gender, low social support, premorbid psychiatric diagnosis, and greater than 5 appropriate or inappropriate defibrillations.1
Dr. Warraich challenged healthcare providers at the Houston Shock Symposium to consider the physician role in empowering patients to shift their mindset after an ICD shock from victimhood thinking with poor coping skills to survivorship thinking with strong coping skills.2 Dr. Warraich highlighted the use of the I-DECIDE tool which is a shared decision-making guide to facilitate conversations with patients early and often regarding device placement. Specific times to address therapies includes pre-device implantation, after a major life event, after shock received, with progression of underlying disease, and towards the end of life.
ICD use and discussion is complex for both patients and providers as evidenced by the DECIDE-HF study that surveyed clinicians about barriers to goals of care discussions in hospitalized heart failure patients. DECIDE-HF specifically addressed how ICD-deactivation may be perceived as unethical and as a morally distinct form of treatment withdrawal. Furthermore, studies have analyzed how sociocultural beliefs, region of training and profession influenced provider practices surrounding ICD-deactivation.3
Psychosocial stress is amplified towards the end of life for ICD recipients. Goldstein et al. performed a cross sectional survey between hospice facilities where they found that on average only 42% of patients had their ICD shocking function deactivated while enrolled in hospice.4 Another study by Stoevalaar et al. noted 9% of patients received a shock within the last month of their life.5 Given this complexity regarding ICD impact on our patients, this topic warrants continued conversation and focus in the medical community.
The Houston Shock Symposium brought together a community of interdisciplinary care team members including trainees, seasoned physicians, and advanced practice providers to learn about shock management in all aspects of care. This presentation from Dr. Warraich of psychological stressors related to ICD shocks was eye opening and powerful. By facilitating a thought-provoking discussion and highlighting known clinical tools, conference participants learned valuable lessons on how best to support our patients with heart failure and their families.
Dr. Katie Vaughan is a current chief medical resident at Beth Israel Deaconess Medical Center in Boston, MA and served as a CardioNerds Conference Scholar for the 2023 Houston Shock Symposium. To learn more about shock, enjoy the open-access Journal of Shock & Hemodynamics (JoSH), the official Journal of the Annual Houston Shock Symposium.
References
1: Sears, S., Hauf, J., Kirian, K., Hazelton, G., Conti, J. Posttraumatic Stress and the Implantable Cardioverter-Defibrillator Patient. What the Electrophysiologist Needs to Know. Circ: Arrhythmia and Electrophysiology. 2011; 4:242-250. DOI: 10.1161/CIRCEP.110.957670
2: Ford, J., Sears, S., Shea, J., Cahill, J. Coping With Trauma and Stressful Events as a Patient with an Implantable Cardioverter-Defibrillator. Circulation. 2013;127:e426-e430. DOI: 10.1161/CIRCULATIONAHA.112.127563
3: Landry-Hold, F., Mondesert, B., Day, A.G., Ross, H.J., Brouillette, J., Clarke, B., Zieroth, S., Toma, M., Parent, M-C., You, J.J., Ducharme, A., and DECIDE-HF Investigators. Characteristcs of Clinicians Are Associated with their Beliefs about ICD deactivation: Insight from the DECIDE-HF Study. CJC Open. 2021 Aug; 3(8): 994–1001. DOI: 10.1016/j.cjco.2021.03.006
4: Goldstein, N., Carlson, M., Livote, E., Kutner, J.S. Management of Implantable Defibrillators in Hospice. Ann Intern Med. 2010 Mar 2; 152(5): 296–299. DOI: 10.1059/0003-4819-152-5-201003020-00007
5: Stoevelaar R., Brinkman-Stoppelenburg A., van Driel A.G., Theuns, D.A.M.J., Bhagwandien, R.E., van Bruchem-Visser, R.L., Lokker, I.E., van der Heide, A., Rietjens, J.A.C. Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records. Eur J Cardiovasc Nurs. 2019;18(6):449–457. DOI: 10.1177/1474515119844660.
