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Tuesday, January 31, 2012

Why ICDs Shouldn't Always be Replaced

The implantable cardioverter-defibrillator (ICD) can save lives by recognizing a life threatening heart arrhythmia and immediately shocking the heart back to a normal rhythm. More than 100,000 are implanted each year.

ICD batteries last an average of five years. Here's how the Mayo Clinic talks about battery life:
The lithium battery in your implantable cardioverter-defibrillator can last up to seven years. During your regular checkups, which should occur every three to six months, your doctor or nurse will check the battery. When the battery is nearly out of power, your old shock generator is replaced with a new one during a minor outpatient procedure.
Notice how the final sentence suggests that replacement will automatically be done. There's no reference to the patient's preferences. The implication is that once an ICD is implanted, it will be with us until we die.

An article in the January 26 New England Journal of Medicine - "Time for a Change - A New Approach to ICD Replacement" challenges that assumption. Health status and life circumstances may have changed since implantation such that sudden death from an arrhythmia now looks like a blessing, not a curse.  Or our experience with the ICD may make us not want to replace it.

The authors describe how in our all-too-often fragmented system of care no one physician is responsible for helping the patient decide whether the battery should be replaced. The care system goes onto automatic pilot. As the Mayo Clinic says - the "old shock generator is replaced with a new one during a minor outpatient procedure."

The authors' recommendations are so obviously sensible it's surprising they aren't routine:
  1. A comprehensive medical evaluation should be done before ICD replacement.
  2. There should be clear and full communication among the entire medical team.
  3. The patient's preferences, past experience with the ICD, and advance care planning, should be explicitly included in decision making.
  4. Replacement should only be done if the patient wants it to be done!
I haven't been part of decision-making about an ICD, but I have observed how medicine can go onto automatic pilot. At the end of my first stepmother's life (my father was a three-time widower) she was suffering from terrible shortness of breath. She was put onto a ventilator for comfort. Over a day or two the coma she was in from cancer that had spread to the brain deepened. The ventilator, which initially had relieved suffering, was now prolonging the dying process. I pointed this out to her children (my step-sibs) and they authorized withdrawal of the ventilator, allowing their mother to die peacefully, unattached to any machines.

Not automatically replacing ICDs will save money, but it's not death panel rationing. Ascertaining what our true wishes are and following them is the right way to practice medicine!

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