End-of-life directives rarely include device deactivation

Many patients with cardiovascular implantable electronic devices (CIEDs) that are ultimately deactivated may not make advanced planning for their devices to be turned off at the end of life. A study published in the January issue of JAMA Internal Medicine found that only one patient out of 150 whose ICDs were deactivated addressed the device in advance directives.

Lillian C. Buchhalter of the Mayo Clinic College of Medicine and colleagues sought to learn more about the patients or their surrogates making the decision to deactivate CIEDs. They reviewed medical records of Mayo Clinic patients who were referred for device deactivation between November 2008 and September 2012.

They identified patients with a pacemaker (PM) dependency, which was defined as not having a heart rhythm of 30 beats per minute during back-up pacing and after turning off the CIED’s pacing. Patients with implantable cardioverter-defibrillators who had bradycardia therapies deactivated were combined with patients with PMs who had bradycardia therapies deactivated. The researchers compared this group with patients who underwent only tachycardia therapy deactivation.

There were 159 deactivation requests, but nine were not carried out for different reasons. Prognosis was poor or terminal for 149 of the 150 patients whose devices were deactivated. Deactivation of tachycardia therapies occurred in 79 percent of patients and deactivation of bradycardia therapies either with or without tachycardia therapies occurred in 21 percent of patients, and 4 percent of these latter patients were pacemaker-dependent.

Surrogates made deactivation requests 51 percent of the time and only one patient mentioned the CIED in advance directives, although more than half had advance directives in place. Patients who underwent only tachycardia therapy deactivation lived slightly longer on average than the patients who underwent deactivation of bradycardia with or without tachycardia therapies (3 days vs. 0 days), but the proportion of patients who died within a month of deactivation were similar in both groups (85 percent vs. 94 percent).

“These findings suggest that a decision to deactivate a CIED reflects the seriousness of a given patient’s underlying illness and his or her poor prognosis,” the authors explained.

They also argued that patients’ end-of-life planning should take these devices into account.

In an accompanying editorial, authors Katy Butler, BA, and Sunita Puri, MD, MS, of Stanford University School of Medicine, wrote that end-of-life communication, which includes discussion about CIEDs, is a crucial component of some doctor-patient relationships. However, it is a skill many physicians do not learn.

“Structured training in end-of-life conversations is not currently required in many subspecialty training programs, including cardiology,” they wrote. “We recommend that it be developed and integrated into cardiology curricula and continuing education.”