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Features and outcomes of patients who underwent cardiac device deactivation
Lillian C Buchhalter1, Abigale L Ottenberg2, Tracy L Webster3
1Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minnesota.
Insights
Deactivating cardiovascular implantable electronic devices (CIEDs) often occurs in patients with terminal illnesses. Most patients died within a month of CIED deactivation, highlighting the importance of advance care planning.
Area of Science:
- Cardiology
- Medical Ethics
- Palliative Care
Background:
- Cardiovascular implantable electronic devices (CIEDs) are crucial for managing cardiac conditions.
- Deactivation of CIEDs is a complex decision with limited understanding of patient characteristics and outcomes.
- This study addresses the knowledge gap regarding CIED deactivation scenarios.
Purpose of the Study:
- To characterize patients undergoing CIED deactivation.
- To analyze the outcomes associated with CIED deactivation.
- To explore the role of advance directives and consultations in the deactivation process.
Main Methods:
- Retrospective review of medical records for 150 patients at a tertiary academic medical center.
- Data collected included demographics, clinical status, advance directives, and deactivation details.
- Analysis focused on features and outcomes of CIED deactivation.
Main Results:
- Most patients (99%) had poor or terminal prognoses.
- Deactivation of tachycardia therapies was more common (79%) than bradycardia therapies.
- Surrogate requests (51%) and nurse-led deactivations (55%) were frequent; advance directives rarely mentioned CIEDs.
Conclusions:
- CIED deactivation decisions often reflect underlying severe illness.
- Most patients died within a month post-deactivation, irrespective of therapy type.
- Patients with CIEDs should engage in advance care planning to align care with their wishes.
Importance:
Little is known about patients who undergo cardiovascular implantable electronic device deactivation.
Objective:
To describe features and outcomes of patients who underwent cardiovascular implantable electronic device deactivation.
Design, Setting, And Participants:
Retrospective review of medical records of 150 patients at a tertiary academic medical center (Mayo Clinic, Rochester, Minnesota). EXPOSURE Cardiovascular implantable electronic device deactivation.
Main Outcomes And Measures:
Demographic and clinical data and information regarding advance directives, ethics consultations, palliative medicine consultations, and cardiovascular implantable electronic device deactivations.
Results:
Of the 150 patients (median age, 79 years; 67% were male), 149 (99%) had poor or terminal prognoses. Overall, 118 patients (79%) underwent deactivation of tachycardia therapies only, and 32 (21%) underwent deactivation of bradycardia therapies with or without tachycardia therapies (6 patients [4%] were pacemaker-dependent). Half of the deactivation requests (51%) were made by surrogates. A majority of deactivations (55%) were carried out by nurses. Although 85 patients (57%) had advance directives, only 1 mentioned the device in the directive. Ethics consultations occurred in 3 patients (2%) and palliative medicine consultations in 64 (43%). The proportions of patients who died within 1 month of device deactivation were similar for those who underwent deactivation of tachycardia therapies only and those who underwent deactivation of bradycardia therapies with or without tachycardia therapies (85% vs 94%; P = .37).
Conclusions And Relevance:
Most requests for cardiovascular implantable electronic device deactivation were for implantable cardioverter-defibrillator-delivered tachycardia therapies only. Many of these requests were made by surrogates. Advance directives executed by patients with these devices rarely addressed device management. Regardless of device therapy, most patients died shortly after device deactivation. Hence, a device deactivation decision may reflect the seriousness of a given patient's underlying illness. Patients with devices should engage in advance care planning to ensure that future care is consistent with their preferences.
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