Documented consent process for implantable cardioverter-defibrillators and implications for end-of-life care in older adults

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at risk for life-threatening heart arrhythmias, and their use is increasingly common. However, these devices also confer risk for delivery of unexpected painful shocks during the dying process, thus reducing the quality of palliative care at the end of life. This scenario can be avoided by ICD deactivation in appropriate circumstances but patients will remain unaware of this option if not informed about it. It is not known how often end-of-life implications are discussed with patients prior to ICD implantation, when focus is primarily on the short-term potential complications of the device placement procedure itself. We conducted a retrospective chart review to determine how often end-of-life implications were discussed with patients as part of the informed consent process. We evaluated consent forms and related other chart documentation for 91 patients (ranging from age 60 to 89 years) undergoing first-time ICD placement at a mid-western academic medical center from 2006-2008. Only one chart documented any discussion of end-of-life implications, in a case where the issue was raised by a patient who noted that quality of life was their main focus. Consent was provided by a health care surrogate in only four of the 91 cases. In conclusion, patients giving consent for ICD implantation may be uninformed about the device's potential future impact on end-of-life care, the dying process, and the option for device deactivation. Truly informed consent requires that both short- and long-term potential implications be reviewed with patients.