Communication training improves end-of-life discussions between HF patients, physicians

A 90-minute communication skills course improved conversations about implantable cardioverter-defibrillator (ICD) deactivation and goals of care between clinicians and their patients, according to the recently published results of the WISDOM study.

Nathan E. Goldstein, MD, of the Icahn School of Medicine at Mount Sinai and James J. Peters Veterans Affairs Medical Center in the Bronx, New York, and colleagues set out to determine whether a clinician-centered teaching intervention and automatic reminders could improve ICD deactivations and end-of-life discussions among patients with heart failure. Writing in the Journal of the American College of Cardiology, the authors said HF patients often benefit from ICDs, but they also typically die of heart failure or other diseases.

ICD shocks toward the end of a person’s life can be traumatic, Goldstein and co-authors wrote, for both patients and their loved ones. Research has shown that more than a quarter of ICD recipients might receive repetitive shocks in the last days and hours of their lives, which can be physically and emotionally painful.

“To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function,” the authors said.

The WISDOM (Working to Improve Discussions about Defibrillator Management) trial comprised 525 subjects—301 intervention participants and 224 controls— with advanced HF and an ICD who were treated at one of six centers. At baseline, the majority of patients (52%) were not candidates for advanced therapies like cardiac transplant or mechanical circulatory support.

The actual intervention involved an interactive 90-minute communication skills training session on advance care planning for physicians, with an emphasis on ICD deactivation and goals of care. Clinicians in the intervention group also received automated electronic reminders about what they learned and earned $100 for their participation in the project.

Goldstein et al. ultimately found that 14% of patients in the intervention group and 12% of patients in the control group had a discussion with their doctor about deactivating their ICD. There were 33 deactivations in the intervention group (11% of patients) and 26 in the control group (12% of patients), but adjusted models didn’t reveal any significant differences between the cohorts.

Still, in prespecified subgroup analyses of patients who weren’t candidates for advanced therapies, the ICD intervention increased discussions of deactivation (25% of patients in the intervention group vs. 11% of patients in the control group). There was an increase in goals of care conversations among all participants—47% in the intervention group vs. 38% in the control group.

“The intervention led to a doubling of conversations about ICD deactivation in patients who were not candidates for advanced cardiac therapies who were cared for by clinicians who underwent the communication training,” Goldstein and co-authors wrote. “Patients cared for by clinicians who underwent the intervention also had increased goals of care conversations.”

The finding that the intervention changed conversations in patients without an indication for advanced therapy suggests cardiologists tailored their communication training to individual patients’ clinical status and needs, the authors said. On the other hand, the lack of an impact on ICD deactivation could be explained by the fact that just half of patients had functional impairment at baseline, and some patients prefer to deactivate their ICDs when they’re closer to death.

“Given the increased focus on improving advance care planning conversations in patients with HF and the workforce shortage of clinicians who specialize in palliative care, our intervention has substantial potential to improve the communication skills of frontline clinicians caring for patients with advanced HF,” Goldstein et al. said.