Deepa J Thoppil

Scholarly Project Advisor: Marilyn A. Prasun PhD, CCNS, CNL, CHFN, FAHA

Affiliated Organization where the project occurred: Jesse Brown Veterans Affairs Medical Center, Chicago, IL.

Any Funding you received for the Project: No funding was received for this project.

Introduction/Problem

Implantable cardioverter-defibrillator (ICD) is an appropriate therapy for cardiac arrest prevention; however, shock therapy from the device in the final days of life can negatively impact the quality of life and death of patients. Professional guidelines recommend cardiac electrophysiology providers discuss the option of shock therapy deactivation at end-of-life (EOL) with the patients starting before the ICD implant. Yet, many elderly and terminally ill patients have ICDs with active shock therapy and are not aware of the associated risks or recommended actions, revealing a practice gap.

Methods

A quality improvement project was implemented in the outpatient setting of an urban Veteran’s Affairs Medical Center to improve the knowledge and attitude of patients with an ICD towards EOL device management discussions and actions, and to promote advanced decision-making on EOL ICD management. The interventions included shared decision-making before primary prevention ICD implant, brief mention of EOL ICD options during ICD procedure consent, and a 15-minute-long nurse practitioner-led patient education session in the device clinic, where patients with an ICD routinely follow up. The patient education was supported with a newly-developed educational handout. The Experiences, Attitudes and Knowledge of End-of-Life Issues in Implantable Cardioverter Defibrillator Questionnaire (EOL-ICDQ) was used to measure the impact of the education session.

Findings

90 patients completed the pre- and post-education survey. Most participants reported never discussing the ICD shock deactivation procedure with an ICD doctor or nurse. Patients’ ICD knowledge was low at baseline, however, the mean knowledge score improved significantly after the education session. There were significant positive differences in responses to all 10 knowledge items and five out of 15 attitude items on the EOL-ICDQ questionnaire after the education session. Even with poor baseline ICD knowledge, most patients were open to providers discussing EOL device management options. Advance directive consultation was requested for patients who exressed interest in documenting ICD wishes in advance directives, all are still in process. Further work is needed to assess the long-term impacts of the project.

Practice Implications

Nurse practitioner-led patient education in the device clinic improved the knowledge and attitude of patients with an ICD. Patients appreciated the ICD education offered by the device nurse practitioners. Involving social workers was essential to improve the documentation of ICD wishes in the advance directives. The only potential risk with the interventions was the possibility of causing anxiety for patients in considering their wishes at EOL. Because this was a single-site project focused on the veteran population composed of mostly males, the generalizability of the findings is limited to device clinics at other Veterans Health Affairs facilities.