Implantable cardioverter-defibrillator shocks in dying patients: disturbing data from beyond the grave.

I mplantable cardioverter-defibrillators (ICDs) are well documented to save lives in many patient groups for primary and secondary prevention; however, although the ICD is highly effective at preventing sudden death, everyone will die eventually, whether of underlying heart disease or other terminal illness such as malignancy. As the population of patients living with ICDs expanded, case reports began appearing in the palliative care literature such as, " Death and defibrillation: a shocking experience " 1 and " And it can go on and on and on. " 2 ICD shocks are painful, described by patients as " a punch in the chest, " " being kicked by a mule, " and " putting a finger in a light socket, " 3 and it is not surprising that receiving shocks at the end of life would be a distressing experience for the dying patient as well as his or her family. How often this actually happened was first described by our group in 2004. Interviewing family members of deceased patients from our practice, we found that 20% were reported to have received shocks in the last weeks, days, or hours of their lives. 4 More recently, Sherazi et al 5 reviewed charts of 98 patients receiving ICDs in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT-2) who later died, finding that only 15% had had their ICDs deactivated, many after receiving shocks in the last week of life. The true frequency of ICD shocks in dying patients, however, was likely underestimated by both of these studies, because neither family nor healthcare providers may have been aware of all shocks received, and in many cases, the only individuals who could have provided the accurate answer may have carried it with them to the grave. The study by Kinch Westerdahl et al 6 in this issue of Circulation provides a definitive answer to this question, reaching beyond the grave to perform postmortem device interrogation in addition to chart review in a series of 130 patients who died between 2003 and 2010. Among these, 35% had ventricular arrhythmias in the last hour before death, and 31% received a shock in their last 24 hours, including many with arrhythmia storms, some receiving >10 shocks in their final hours. Patients may not have been able to describe these to family or healthcare providers, yet it is likely that close to a third of ICD patients may …