Improving implantable cardioverter defibrillator deactivation discussions in admitted patients made DNR and comfort care

Abstract

Background: Unintended shocks from implantable cardioverter defibrillators (ICDs) are often distressing to patients and family members, particularly at the end of life. Unfortunately, a large proportion of ICDs remain active at the time of death among do not resuscitate (DNR) and comfort care patients.

Methods: We designed standardised teaching sessions for providers and implemented a novel decision tool in the electronic medical record (EMR) to improve the frequency of discussions surrounding ICD deactivation over a 6-month period. The intended population was patients on inpatient medicine and cardiology services made DNR and/or comfort care. These rates were compared with retrospective data from 6 months prior to our interventions.

Results: After our interventions, the rates of discussions regarding deactivation of ICDs improved from 50% to 93% in comfort care patients and from 32% to 70% in DNR patients. The rates of deactivated ICDs improved from 45% to 73% in comfort care patients and from 29% to 40% in DNR patients.

Conclusion: Standardised education of healthcare providers and decision support tools and reminders in the EMR system are effective ways to increase awareness, discussion and deactivation of ICDs in comfort care and DNR patients.

Keywords: patient preference; patient-centred care; quality improvement; standards of care.

Figure 1

Run charts. Twenty-eight-week study period for (A) comfort care cohort and (B) DNR cohort showing the documented discussion rate (solid line) and the ICD deactivation rate (dotted line). Each data point reflects the percentage of successful outcomes divided by the total number of patients up to that week of data collection. The horizontal red dotted line is to compare with the rate of documented discussions or ICD deactivations in the retrospective data prior to any interventions. Study interventions are listed along the x-axis. DNR, do not resuscitate; EMR, electronic medical record; ICD, implantable cardioverter defibrillator; NP, nurse practitioner; PA, physician assistant.

Figure 2

Provider awareness of ICD status. Weekly survey targeting providers who entered DNR and/or comfort care orders. Ten DNR patients and five comfort care patients were selected at random using a number generator. (A) The comfort care order set was added on week 14. Providers who answered ‘Y’ were 49% (24/49) pre-EMR vs 95% (36/38) post-EMR change (p<0.01). (B) The DNR document pop-up was added on week 18. Providers who answered Y were 48% (63/131) pre-EMR vs 93% (40/43) post-EMR change (p<0.01). DNR, do not resuscitate; EMR, electronic medical record; ICD, implantable cardioverter defibrillator; N, no; Y, yes.