Training, Triggers, and a Team for the Right Discussions

OBJECTIVE: To determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. 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. METHODS: We conducted a 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: We report on 525 subjects with advanced HF who had an ICD – 301 intervention and 224 control. At baseline 52% (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 not candidates for advanced therapies, the intervention increased deactivation discussions (32 (25%) vs. 16 (11%); OR 2.90, P = 0.003). Overall 99 patients died; there were no differences in conversations or deactivations amongst decedents. Secondary Outcomes: Among all participants there was an increase in goals of care conversations (47% intervention vs. 38% control, OR 1.53, P = 0.04). There were no differences in completion of advance directives. CONCLUSIONS: Our 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. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov