Patient and Professional factors that impact the perceived likelihood and confidence of healthcare professionals to discuss Implantable Cardioverter Defibrillator deactivation in advanced heart failure: Results from an International Factorial Survey

Background: Rate of ICD implantations is increasing in patients with advanced heart failure. Despite clear guideline recommendation, discussions addressing deactivation occur infrequently. Aim: To explore patient and professional factors that impact perceived likelihood and confidence of healthcare professionals to discuss ICD deactivation. Methods and Results: Between 2015 and 2016, an international sample of 262 healthcare professionals (65% nursing; 24% medical) completed an online factorial survey, encompassing demographic questionnaire and clinical vignettes. Each vignette had nine randomly manipulated and embedded patient-related factors, considered as independent variables, providing 1,572 unique vignettes for analysis. These factors were determined through synthesis of a systematic literature review, retrospective case note review and qualitative exploratory study. Results showed most healthcare professionals agreed deactivation discussions should be initiated by a cardiologist (95%, n=255) or specialist nurse (81%, n=215). In terms of experience, 84% (n=53) of cardiologists but only 30% (n=50) of nurses had previously been involved in a deactivation decision. Healthcare professionals valued patient involvement in deactivation decisions, however only 50% (n=130) actively involved family members. Five out of nine clinical factors were associated with an increased likelihood to discuss deactivation including advanced age, severe heart failure, presence of malignancy, receipt of multiple ICD shocks and more than three hospital admissions during the previous year. Furthermore, nationality and discipline significantly influenced likelihood and confidence in decision-making. Conclusions: Guidelines recommend healthcare professionals discuss ICD deactivation, however practise is sub-optimal with multifactorial factors impacting on decision-making. The role and responsibility of nurses in discussing deactivation requires clarity and improvement.