Enhancing the Adequate Information and Approval Procedure for Defibrillators in Older Adults: Justifying Bioethicist Participation
In the United States, approximately 140,000 Automated Implantable Defibrillators (AICD) are implanted annually for sudden death prevention. The majority of these implantations (over 60%) are performed on individuals aged 65 years or older. However, a growing body of evidence suggests that the healthcare system may not be adequately considering the needs of senior citizens in terms of technological intervention.
The consent process for AICD placement in elderly patients focuses on immediate procedural risks but rarely mentions midterm or long-term risks. These risks, such as inappropriate shocks, device malfunction, recalls, the need for replacement, anxiety and depression, impact on the patient's significant other, and even painful death when the AICD discharges, are crucial for patients to understand before making an informed decision.
A study of patients with heart failure found that they overvalued sevenfold the value of an AICD, but it does not confer any symptomatic benefit at any age, and for many patients in their 80s and 90s, it does not confer a survival advantage either. This misperception of benefits can lead to unnecessary procedures and potential harm for senior citizens.
The ideal consent process for AICD implantation should include more than one care provider, such as the Electrophysiology Cardiologist, the patient, the surrogate decision-maker, and perhaps others in a collaborative process assisted by decision aids. Bioethicists' involvement can help restore an appropriate balance in the care of older patients in this regard to the AICD device in the U.S. They may provide useful input to the development of their institution's policy regarding AICDs.
Decision aids have been developed to help patients and their surrogates understand the process, risks, benefits, and alternative choices. Consultation with other services such as psychology, ethics, or palliative care services may be helpful in improving the decision-making process.
Several other Western countries handle this medical situation with much less use of these devices in elderly patients without noticeable differences in mortality. This suggests that a more nuanced approach to AICD implantation in senior citizens may be warranted.
It is important to note that AICD implantation for primary and secondary prevention of sudden death is a common practice. However, the benefits of AICD implantation for senior citizens are often modest or minimal. The National ICD registry shows that over half of those aged 65 and older who receive an AICD are dead or in hospice 5 years after implantation. A significant portion (42%) of AICD implantations are done on people over the age of 70.
The number of AICD implantations might have decreased during the COVID pandemic. This could be due to several factors, including a shift in focus towards managing the pandemic, or a reevaluation of the benefits and risks of these procedures in the context of limited resources.
Todays' digital communication programs make it possible to conduct the consent process remotely and asynchronously. This could potentially improve access to informed consent for AICD implantation, especially for those in remote or underserved areas.
Before the referral to the Electrophysiology Cardiologist, the goals of medical care need to be thoroughly discussed with the patient's next of kin, healthcare surrogate, general cardiologist, primary care physician, and EPC nurse. This holistic approach can help ensure that the patient's wishes and needs are considered throughout the process.
The healthcare system must strive to provide the best possible care for all patients, regardless of age. In the case of AICD implantation in senior citizens, this means a more nuanced approach that takes into account the unique needs, risks, and benefits for this population. By doing so, we can help ensure that these patients are truly informed and that resources are used fairly and effectively.
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