Prevalence, predictors, and outcomes of advance directives in implantable cardioverter-defibrillator recipients

Abstract

Background: Little is known about advance directive (AD) utilization in implantable cardioverter-defibrillator (ICD) recipients.

Objective: The purpose of this study was to define the prevalence and predictors of ADs in patients with ICDs.

Methods: We identified ICD recipients with ADs at our institution. The primary end point was the prevalence of an AD documented up to 1 year after device implant and the secondary end point was the cumulative prevalence of an AD.

Results: Of 2549 patients with ICDs, 701 (27.5%) were followed for at least 1 year after device implant, and of those 701 patients, 164 (23.4%) had ADs documented before or within 1 year of ICD implant. The prevalence of ICD recipients with ADs increased overtime, reaching approximately 10% in the most recent years of analysis. However, only 1 AD specifically addressed the ICD as part of end-of-life decision making. In multivariable analysis, more recent year of device implant and prior cardiovascular hospitalization were positively associated with having an AD within 1 year of implant. The cumulative prevalence of an AD at any time after implant reached about 30%, with more recent implant year, prior cardiovascular hospitalization, and palliative care consultation positively associated with the presence of an AD and black race associated with a lower cumulative prevalence.

Conclusion: In a tertiary academic medical center, most patients with ICDs still do not have ADs, and even when they do, the ICDs are rarely addressed as part of the directive. Several predictors of ADs emerged, which may provide opportunities to improve utilization of ADs in ICD recipients.

Keywords: Advance directives; Deactivation; Heart failure; Implantable cardioverter-defibrillator; Palliative care; Palliative care consultation.