Lost in translation: examining patient and physician perceptions of implantable cardioverter-defibrillator deactivation discussions.

S ince its introduction into mainstream clinical practice in the 1980s, the implantable cardioverter-defibrillator (ICD) has become the treatment of choice for potentially life-threatening ventricular arrhythmias. 1 ICDs are recommended by the American College of Cardiology/American Heart Association/ Heart Rhythm Society in select patients as primary prevention to lower the risk of sudden cardiac death. Estimates of ICD prevalence in Canada number >110 000 people with an annual growth rate of 4%, which corresponds to an equivalent prevalence of >700 000 in the United States. 4 ICDs work by sensing ventricular tachycardia and ventricular fibrillation and restoring the underlying rhythm via antitachy pacing (ventricular tachycardia) or through delivering an electric shock across the myocardium (ventricular tachycardia/ventricular fibrillation). 5 Despite their proficiency in preventing sudden cardiac death, ICDs cannot remedy the underlying cardiac abnormality, hence patients ultimately develop progressive heart failure, a trajectory the ICD cannot improve. As their condition worsens , patients with heart failure may develop hypoxia, sepsis, and electrolyte imbalances, which can serve to further poten-tiate arrhythmia, subsequently increasing shock frequency. 6 ICD shocks may in this setting become undesirable. ICDs have been unequivocally shown to prolong life. However, in some patients they do so at the expense of painful shocks that diminish patients' self-perceived quality of life. 7 Approximately 30% of ICD patients experience shocks in the minutes before death. 8 Some patients have likened these electric shocks to being kicked in the chest by a horse. 9 In an investigation comparing quality of life measures in ICD patients and those administered a pharmacological intervention , both physical and psychological functioning were diminished in the ICD group, especially in those who received >5 shocks. 6 Furthermore, the generally adverse and unpredictable timing of an ICD shock was found to be a source of psychological distress. 10 The number of years since implantation and number of ICD discharges were also positively correlated with anxiety, which occurs in 13% to 38% of patients. This psychological burden is occasionally transferred to the patient's family because both patients who received shocks and their family members possessed higher levels of mood disturbance than shock-naive patients. 13 In addition, these symptoms may predispose to arrhythmia, potentially increasing one's propensity for future shocks. 14 Deactivation of an ICD involves reprogramming the device or using an external magnet to disable the ICD's shocking and antitachycardia pacing functions. It is warranted under circumstances in which the …