Improving Communication in Heart Failure Patient Care

Abstract

Background: Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function.

Objectives: The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation.

Methods: In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion.

Results: A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents.

Secondary outcomes: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives.

Conclusions: The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).

Keywords: communication; heart failure; implantable defibrillator; palliative care.

Central Illustration:. Improvement in implantable Cardioverter-Defibrillator Deactivation Conversations.

Clinicians were taught communication techniques to determine patients’ goals for their healthcare and to use those goals to help patients make treatment decisions related to their heart failure and their implantable cardioverter-defibrillator (ICD). Graphs demonstrate increased discussions in all patients, in those who were not candidates for cardiac transplant or mechanical circulatory support, and in those who died. Changes in discussions were only significant in those who were not candidates for advanced therapies. There were no significant differences in deactivating the shocking function of the ICD. For all bars, data presented for deactivation is the subset of those patients who reported a discussion. Number of patients in each bar is presented in parentheses under the percentage of patients in that category (i.e., N is underneath the %).

Figure 1:

CONSORT Diagram for the Working to Improve diScussions about DefibrillatOr Management (WISDOM) Trial. Patients were enrolled from 6 academic medical centers across the country based on specific enrollment criteria (Online Appendix) to predict high risk of death. Randomization took place at the level of the medical center, before any patients were enrolled. If patients could not be contacted for two consecutive follow-up interviews, they were considered lost to follow-up. If patients were lost to follow up and had no inpatient or outpatient data after the second missed interview, then no final data were available for them.