Lessons from the Literature

2021; Volume 22, No 6, June

Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Under My Microscope

Dr. Tania Pastrana. Used with permission.

By Dr. Tania Pastrana
IAHPC Research Advisor

Implantable Cardioverter Defibrillator Devices: When, how and who should discuss deactivation with patients: A systematic literature review

Freemantle M, Murtagh F. BMJ Support Palliat Care 2021. Epub ahead of print. DOI: 10.1136/bmjspcare-2021-002894

The first human implantation of an implantable cardioverter defibrillator device (ICD) was back in the 1980s,1 and the number of patients who need and receive IDCs increases over time. Last week we admitted yet another patient with an ICD to our ward. I noticed the stress on everyone—the patient, their relatives, and health care personnel—due to fear of the unpredictable arrhythmia, and painful and distressing shocks that can occur in their last phase of life for those with an ICD, as described by Stoevelaar et al.2

I came across with this article, written by Megan Freemantle and Fliss Murtagh, in which the authors conducted a systematic review of key aspects of ICD deactivation. The 22 studies included (of 8,893 identified) in the review were conducted between 2011 and 2019 in the United States (9), Sweden (5), the United Kingdom (3), Canada (2), Ireland (1), the Netherlands (1), and a joint paper from the USA/Australia. The authors identified no studies from low- or middle-income countries.

They concluded that, despite available guidelines, conversations regarding deactivation are not always followed in practice, and there is limited training in communication skills. They suggested that a proactive clinical and policy initiative in the education of both professionals and patients and their relatives about device deactivation would prevent distress and promote comfortable dying.

  1. Matchett M, Sears SF, Hazelton G, Kirian K, Wilson E, Nekkanti R. The Implantable Cardioverter Defibrillator: Its history, current psychological impact and future. Expert Rev Med Devices 2009; 6(1): 43-50. DOI: 10.1586/17434440.6.1.43
  2. Stoevelaar R, Brinkman-Stoppelenburg A, Bhagwandien RE, van Vruchem-Visser RL, Theuns DA, et al. The Incidence and Impact of Implantable Cardioverter Defibrillator Shocks in the Last Phase of Life: An integrated review. Eur J Cardiovasc Nurs 2018; 17(6): 477-485. DOI:10.1177/1474515118777421

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Background: Implantable cardioverter defibrillators (ICDs) are used to treat life-threatening cardiac arrhythmias and prevent sudden cardiac arrest. As recipients age they may develop greater risk of dying as a result of progressive multimorbidity rather than sudden cardiac death. Defibrillation shocks may prolong an uncomfortable dying process. Deactivation of the defibrillator would prevent this, yet is not always discussed and planned.

Aim: To systematically review published evidence on ICD deactivation discussions and make recommendations on when, how and who should facilitate effective and patient-centred deactivation discussions.

Methods: Using standard systematic review methods, MEDLINE, EMBASE, CINAHL and PsycInfo were searched for studies published in the English language between 2010 and March 2021. Inclusion criteria were studies of adults (≥18 years) and including discussions on ICD deactivation and/or related communication. Included studies were independently reviewed, data extracted, quality assessed and data synthesised using a deductive approach.

Results: Of the 8893 articles identified, 22 papers met the inclusion criteria. Deductive approach led to identification of five main themes: (1) timing of ICD deactivation discussions, (2) initiation of deactivation discussions, (3) advance directives, (4) barriers to discussions and (5) facilitators of discussions.

Conclusions: Despite available guidelines, conversations on device deactivation are not being undertaken consistently. Evidence suggests lack of professional awareness of guidelines and limited training in communication skills. To prevent distress and promote comfortable dying, there needs to be a proactive clinical and policy initiative in the education of both professionals and patients and their relatives about device deactivation.

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Media Watch: Education

This fertile topic has produced a second selection (the May issue also dealt with education) from recent issues of Barry R. Ashpole’s weekly report, Media Watch.

Clinical Practice

Project ECHO: Enhancing palliative care for primary care occupational therapists and physiotherapists in Ireland

Health & Social Care in the Community | Online – 15 May 2021 – As Project ECHO (Extension for Community Healthcare Outcomes) addresses disparities in access to care and slow dissemination of best practices within existing resources, it offers much potential to expand capacity in resource constrained contexts. Overall, results from this study support the use of Project ECHO for healthcare professionals palliative care (PC) education in primary care. The utility of this format was confirmed as an effective and accessible model. Findings demonstrate positive impact on confidence in self‐rated knowledge and skills and on establishing a network of practice between specialist services and primary care, across disciplines and geographical areas. Future developments to nurture local relationships formed to ensure sustainable practice change were highlighted to ensure ECHO directly impacts service delivery and improves the capacity of quality PC provision. DOI: 10.1111/hsc.13372

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Children’s palliative care education and training: Developing an education standard framework and audit

Research Square | Online – 21 April 2021 – The need to align the range of guidance and competencies concerning children’s palliative care (PC) and develop an education framework was recommended by the U.K. All-Party Parliament Group... Four sections depicting developing levels of knowledge and skills were identified: Public Health, Universal, Core, Specialist. Each level has four learning outcomes: Communicating effectively; Working with others in and across various settings; Identifying and managing symptoms; and Sustaining self-care and supporting the well-being of others. An audit tool template was developed to facilitate quality assurance of programme delivery. The framework and audit tool repository is on the International Children’s Palliative Care Network website for ease of international access. DOI: 10.21203/rs.3.rs-418065/v1

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Public Education

First experiences with online Last Aid courses for public palliative care education during the COVID-19 pandemic

Public Health | Online – 5 February 2021 – The Last Aid course aims to teach public palliative care (PC) by increasing public awareness and empowering people about the role of the individual in the death of loved ones. The COVID-19 pandemic, however, has altered educational methods prohibiting classroom settings. Therefore, an online course was created to enable continued and safe public PC education. Findings of this mixed-methods study revealed overall course satisfaction for the online courses in line with previous findings for classroom teaching. The online platform enabled course participation from people previously unable or unwilling to attend, namely caregivers to dying relatives and younger people. Instructors displayed an ability to teach online. However, some instructors expressed frustration over reduced interaction and technical challenges, which was echoed by participant ratings showing that many lacked social networking with fellow participants.

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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