Kelley Amy S, Reid M Carrington, Miller David H, Fins Joseph J, Lachs Mark S
University of California Los Angeles, USA.
Am Heart J. 2009 Apr;157(4):702-8.e1. doi: 10.1016/j.ahj.2008.12.011. Epub 2009 Feb 23.
Among older adults, implantable cardioverter-defibrillator (ICD) use is increasing. ICD shocks can occur at end of life (EOL) and cause substantial distress, warranting consideration of ICD deactivation discussions. This nationwide physician survey sought to (1) determine if physicians discuss ICD deactivation at the EOL, (2) identify predictors of those discussions, and (3) ascertain physicians' knowledge/attitudes about ICD use.
We surveyed 4,876 physicians stratified by specialty (cardiologists, electrophysiologists, general internists, and geriatricians). The mailed survey presented 5 vignettes (eg, end-stage chronic obstructive pulmonary disease, advanced dementia) wherein ICD deactivation might be considered and 17 Likert-scaled items.
Five hundred fifty-eight (12%) physicians returned surveys. Respondents were largely men (77%) and white (69%). Most physicians (56%-83%) said they would initiate deactivation discussions in all 5 vignettes, whereas significantly more (82%-94%) would discuss advance directives and do not resuscitate status. In logistic regression analyses, a history of prior deactivation discussions was an independent predictor of willingness to discuss deactivation (adjusted OR range, 2.8-8.8) in 4 of the 5 vignettes. General internists and geriatricians were less likely than electrophysiologists to agree that ICD shocks are painful and to distinguish between the ICD's pacing and defibrillator functions. Finally, most physicians believed that informed consent for ICD implantation should include information about deactivation (77%) and endorsed the need for expert guidance in this area (58%).
Most physicians would discuss ICD deactivation at EOL. The strongest predictor of this was a history of prior discussions. Knowledge about ICDs varies by specialty, and most expressed a desire for more expert guidance about ICD management at EOL.
在老年人中，植入式心脏复律除颤器（ICD）的使用正在增加。ICD电击可在生命末期（EOL）发生，并造成极大痛苦，因此有必要考虑进行ICD停用的讨论。这项全国性的医生调查旨在：（1）确定医生是否在EOL讨论ICD停用；（2）确定这些讨论的预测因素；（3）确定医生对ICD使用的知识/态度。
我们对4876名按专业分层的医生（心脏病专家、电生理学家、普通内科医生和老年病学家）进行了调查。邮寄的调查问卷给出了5个病例（如终末期慢性阻塞性肺疾病、晚期痴呆症），其中可能会考虑停用ICD，并设有17个李克特量表项目。
558名（12%）医生回复了调查问卷。受访者大多为男性（77%）和白人（69%）。大多数医生（56%-83%）表示，他们会在所有5个病例中发起停用讨论，而表示会讨论预立医疗指示和不进行心肺复苏状态的医生明显更多（82%-94%）。在逻辑回归分析中，既往有停用讨论史是在5个病例中的4个病例中愿意讨论停用的独立预测因素（调整后的OR范围为2.8-8.8）。普通内科医生和老年病学家比电生理学家更不太可能认同ICD电击是痛苦的，也不太能区分ICD的起搏和除颤功能。最后，大多数医生认为ICD植入的知情同意应包括有关停用的信息（77%），并认可在这一领域需要专家指导（58%）。
大多数医生会在EOL讨论ICD停用。最强的预测因素是既往有讨论史。对ICD的了解因专业而异，大多数医生表示希望在EOL获得更多关于ICD管理的专家指导。
