Healthcare Professionals' Perspectives on Implantable Cardioverter Defibrillator Deactivation: A Systematic Review

Introduction: In an era of advancing technology and clinical expertise, many dying patients with an Implantable Cardioverter Defibrillators (ICD) experience inappropriate shocks. Professional guidance to improve patient care is urgently needed.Aim: To evaluate the evidence on healthcare professionals’ perspectives on ICD deactivation at end-of-life.Methods: A systematic search of six electronic databases, using key terms identified from a preliminary scoping exercise. Empirical studies, as well as articles recommended by experts and citations, that met the inclusion criteria, were included. Twenty-two articles were selected and assessed for eligibility, resulting in 12 studies reviewed for quality (Hawker et al. 2002). Consensus from the research team was obtained before findings from all 12 studies were synthesised using narrative approach (Popay et al. 2006).Results: Studies included a total of 3535 professionals and representatives from 47 European centres. Majority (n=9) of studies were conducted in United States of America. Three main themes identified, Reluctance to initiate the discussion was found across all clinical practice settings. There was generalized agreement that the discussion should be initiated by a cardiologist, however there was diverse opinion (n=5) on the appropriateness of this discussion during pre-implantation consent process. Routinely, professionals associated the discussion with a Do-Not-Resuscitate order. Ethical and legal concerns were portrayed in most studies (n=7). Professionals agreed deactivation was ethically and legally permissible when the patient was terminally ill. Concerns were highlighted regarding the management of the patient with cognitive impairment. Desire for improved knowledge and guidance was mentioned by nine studies. Professionals not employed within a cardiac specialty requested additional knowledge and skills. Expert guidelines could be used to inform institutional protocols, flexible to meet the needs of individual patients.Conclusion: A paradigm shift in terms of who is responsible for this decision is overdue. A multidisciplinary team approach would encourage nursing staff to play a pivotal role concerning ICD deactivation.