The thing is: I am a real fan of ICDs. I could fill this blog with ‘good’ ICD stories. These would be vignettes that describe real people who have gained beautiful years of life because of an automatically delivered shock from a device that a former paper boy implanted.
Like all things therapeutic, there are the downsides. Excluding their high cost, ICDs harbor two biggies:
- ICDs only work in a narrow swath of patients that are sick enough to be at risk of cardiac arrest but well enough to not die of something else. Patient selection is key. And it isn’t easy. Smart people, including payers, argue about which patients benefit from the ICD.
- ICDs have serious risks: surgical complications, infections in the bloodstream, inappropriate shocks, hardware recalls and the most tragic of all, trading a painless quick death to one that’s not.
If a doctor is not careful, let’s say nuanced, ICDs can accomplish one of the outcomes I fear most: They can make a person worse. They can do harm. I loath making a patient worse with one of my treatments. It nearly fibrillates my atria.
This is why it is so important to have frank and open discussions with patients. They need to know that neither the device nor doctor are flawless.
You would think pre-ICD discussions would be routine and obvious. But they are not. For a number of reasons: First, neither doctors nor patients like talking about death. Second, heart doctors are ingrained with an ethos that considers death a failure of therapy. As such, many heart doctors take the view that preventing death is more important than considering a patient’s preference. Finally, many heart doctors do not consider ICDs (or the many pills they prescribe) a burden to patients.
These factors have led to the idea that implanting an ICD does not lend itself to shared-decision making.
I disagree with that idea.
And of course I wrote about it over at Trials and Fibrillations on theHeart.org
h/t to Chris Kaiser over at MedPageToday. Chris is a friend and an excellent medical journalist. He alerted me to the Archives of an Internal Medicine Paper that stimulated my thinking about this matter. His article, with a quote from me, is at MedPageToday. Thanks for your support, Chris.