Tuesday, November 8, 2011

Do I need an Implantable cardioverter-defibrillator (ICD)?

What is an Implantable cardioverter-defibrillator anyway? Can I get it shut off? These are the type of questions I get. (BTW I tend to blog in spurts).

So here is the context: A 92 year old male patient of mine with metastatic melanoma, end stage (class 3, stage d) heart failure, recent fall with (a minor) hip fracture came to see me in the office. He had just had an ICD placed in July. This guy's main complaints were: he wants ear wax out so he can hear, he wants to stop urinating at night, he wants to sleep better at night, he wanted to be less short of breath, and stay at home with his wife. He had been hospitalized 5 times in 4 months for CHF and Oncology decided that his melanoma was only treatable with chemotherapy.

Question: What good is an ICD for this guy? This guy wants to avoid surgeries, being debilitated, lingering in pain and ICU's. He does not want aggressive care. If he could choose a way to die, he would like to die peacefully in his sleep. He wants to die in the hospital to avoid stressing out his family but does not want to end up in the ICU.

So what does an ICD do? Well just as a person is about to die peacefully in their sleep, or about to faint, lose consciousness and die painlessly, a large electrical shock wakes them up painfully and restarts their heart. Well for me, I would love that because I have no desire to die in my sleep. But for an older patient that is looking at dying from cancer vs heart failure vs consequences of immobility vs dying peacefully in his sleep, it's easy to see why he picked dying in his sleep painlessly, without being short of breath as his preferred way of dying. BUT an ICD is designed to prevent that specific way of dying.

The other thing to note is that the ICD often has false electrical shocks (of which this guy has had one), does not prevent death in all circumstances (asystole or when the heart stops altogether) and if you were to calculate a NNT (number needed to treat) it would likely be in the teens to 20's somewhere. In other words, it does not help the majority of people, and in those it helps, it likely delays death by months instead of preventing it altogether (kinda obvious but needs to be stated anyway), and it works by preventing what is likely the most peaceful way of dying.

Again, if you are a 45 year old person with a passion for life, a tolerance for medical procedures, then go for it. If you are looking at several ways of dying from various medical problems, many of which would cause suffering, then one needs to carefully consider not having an ICD placed which is designed to prevent the most peaceful way of dying I can think of.