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  • Review Article
  • Published:

Effective communication and ethical consent in decisions related to ICDs

Nature Reviews Cardiology volume 8, pages 694–705 (2011)Cite this article

Subjects

Abstract

This Review examines recommendations and principles that promote good decision-making with regard to the insertion, deactivation, and potential malfunction of implantable cardioverter-defibrillators (ICDs). This guidance is important because ICDs are now used for primary and secondary prevention of arrhythmias in more than 20 diverse clinical populations, which accounts for the exponential increase in insertion rates over the past decade. Current guidelines require clinicians to provide personalized, culturally appropriate, and easy to understand information to patients on the benefits and harms of proposed treatment choices; however, obtaining valid informed consent for insertion and deactivation of ICDs is challenging. Initiating early conversations with patients and continuing this dialogue over time, implementation of localized care protocols, increased collaboration (particularly between cardiac and palliative care teams), and the provision of training for all health professionals involved in the care of these patients, can help to ensure that adequate informed consent is maintained throughout their care. In addition to providing information, health professionals should identify and address high levels of anxiety in patients and their next of kin and promote effective communication throughout decision making. In the future, use of standardized checklists or decision aids based on a clear understanding of the principles underlying key topics could support this process.

Key Points

  • Ensuring that patients give adequate informed consent is a vital part of the decision-making process about insertion and deactivation of implantable cardioverter-defibrillators (ICDs)

  • Health professionals should support patients (and, where appropriate, surrogate decision makers) to make their own decisions about ICD insertion and deactivation

  • Health professionals often do not communicate with or involve patients (or surrogate decision makers) sufficiently in decisions about the ICD, which threatens the ethics and legality of care

  • Clinical guidelines recommend that the decision-making process should be characterized by ongoing dialogue between health professionals and patients, starting early during the care trajectory and involving no coercion

  • ICD deactivation should be discussed before insertion, clinical uncertainties should be acknowledged by health professionals, and benefits and harms fairly presented

  • Health-care decisions can also be supported by good communication skills, local organizational policies and psychosocial interventions provided by multidisciplinary teams

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Acknowledgements

A. M. Clark has received career awards from the Canadian Institutes of Health Research and Alberta Innovates Health Care Solutions.

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Authors and Affiliations

  1. Faculty of Nursing, University of Alberta, Level 3 CSB, Edmonton, TG3 2G3, AB, Canada

    Alexander M. Clark, Megan Jerke & Amanda S. Duncan

  2. Department of Social and Welfare Studies, ISV, 601 74, Norrköping, Sweden

    Tiny Jaarsma

  3. School of Nursing, McMaster University, 200 Main Street West, Hamilton, L8N 3Z5, ON, Canada

    Patricia Strachan

  4. Curtin Health Innovation Research Institute, Curtin House, 39 Regent Street, Chippendale, 2008, NSW, Australia

    Patricia M. Davidson

  5. Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Bordesley Green East, B9 5SS, Birmingham, UK

    James M. Beattie

  6. Cardiovascular Research Centre, Australian Catholic University, VECCI Building, Level 4, 486 Albert Street, Melbourne, 3002, VIC, Australia

    Chantal F. Ski & David R. Thompson

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  1. Alexander M. Clark
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Contributions

A. M. Clark coordinated the writing of this manuscript, contributed to all its sections and oversaw the first and final drafts. Specific authors were responsible for content of this article relating to the following sections: the ethics and legal aspects of implantable cardioverter-defibrillators (A. M. Clark, M. Jerke, A. S. Duncan); guidelines and informed consent (A. M. Clark); current practices and policy and practice around implantable cardioverter-defibrillators and heart failure in Europe (J. M. Beattie, T. Jaarsma); communication issues (P. M. Davidson); anxiety (P. Strachan); and psychosocial interventions (C. F. Ski, D. R. Thompson). All authors contributed to the recommendations for care.

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Correspondence to Alexander M. Clark.

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Clark, A., Jaarsma, T., Strachan, P. et al. Effective communication and ethical consent in decisions related to ICDs. Nat Rev Cardiol 8, 694–705 (2011). https://doi.org/10.1038/nrcardio.2011.101

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