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Characteristics of Clinicians Are Associated With Their Beliefs About ICD Deactivation: Insight From the DECIDE-HF
Florence Landry-Hould1, Blandine Mondésert1, Andrew G Day2
1Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada.
Insights
Clinician beliefs about implantable cardioverter defibrillator deactivation (ICDD) being unethical vary by profession and sociocultural factors. Understanding these influences is crucial for end-of-life discussions with heart failure patients.
Area of Science:
- Cardiology
- Medical Ethics
- Health Services Research
Background:
- Systematic goals of care discussions for heart failure patients are recommended but often not implemented.
- Clinician beliefs regarding the ethics of implantable cardioverter defibrillator deactivation (ICDD) vary, with some viewing it as unethical or physician-assisted suicide.
- Factors influencing these beliefs among healthcare providers are not well understood.
Purpose of the Study:
- To investigate the association between healthcare provider characteristics and their beliefs about ICDD deactivation being unethical or constituting physician-assisted suicide.
- To identify barriers to goals-of-care discussions in heart failure patients.
Main Methods:
- The Decision-Making About Goals of Care for Hospitalized Patients With Heart Failure (DECIDE-HF) survey was administered to 760 clinicians across 9 hospitals.
- Adjusted logistic regression models were used to examine the relationship between respondent characteristics (profession, spirituality, region of training, years in practice) and their beliefs regarding ICDD deactivation.
Main Results:
- Beliefs about ICDD deactivation being unethical differed significantly by profession, with nurses reporting this belief more frequently than fellows or cardiologists (24% vs. 10% vs. 7%).
- Spirituality, region of training (Asia, Middle East compared to Canada), and years in practice were significantly associated with beliefs that ICDD deactivation is unethical.
- Similar associations were found for beliefs that ICDD deactivation constitutes physician-assisted suicide.
Conclusions:
- Sociocultural factors, including spirituality and region of training, alongside professional roles, significantly shape clinicians' ethical views on ICDD deactivation.
- Acknowledging these diverse beliefs is essential for facilitating sensitive end-of-life discussions with heart failure patients.
- Further research may explore tailored communication strategies to address these varied perspectives.
Background:
Discussing goals of care with heart failure patients is recommended but is not done systematically, due to factors such as time and personal beliefs. A recent survey showed that one-fifth of clinicians believe that implantable cardioverter defibrillator deactivation (ICDD) is unethical or constitutes physician-assisted suicide. We investigated whether individuals' characteristics are associated with these beliefs.
Methods:
The Decision-Making About Goals of Care for Hospitalized Patients With Heart Failure (DECIDE-HF) survey was given to healthcare providers at 9 hospitals to assess their perceived barriers to goals-of-care discussions. The association between respondent characteristics and their beliefs was examined using 2 adjusted logistic regression models.
Results:
We included 760 clinicians (459 nurses, 94 fellows, and 207 cardiologists). The responses varied among professions, with the belief that ICDD is unethical considered to be important barrier by nurses (24%), fellows (10%), and staff (7%); P < 0.001). After adjusting for site, spirituality being more important in life (odds ratio [OR]: 2.21; 95% confidence interval [CI]:1.37-3.56; P = 0.001, compared to less important), region of training (Asia [OR: 5.88; 95% CI: 2.12-16.31; P = 0.001] and Middle East [OR: 5.55; 95% CI:1.57-19.63; P = 0.008] compared to Canada), and years in practice (OR: 1.32; 95% CI: 1.07-1.63; P = 0.01 per decade) influenced beliefs about ICDD being unethical, with similar results for the belief that ICDD represents physician-assisted suicide.
Conclusions:
Sociocultural factors, region of training, and profession influence clinicians' beliefs about ICDD being unethical and representing physician-assisted suicide. These factors and beliefs must be acknowledged when facing the delicate issue of end-of-life discussion.
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