The D ecisions, I nterventions, and G oals in Impla N table Cardioverter-Def I brillator T herap Y (DIGNITY) Pilot Study

Abstract

Background: Implantable cardioverter-defibrillators (ICDs) are commonly implanted in older patients, including those with multiple comorbidities. There are few prospective studies assessing the clinical course and end-of-life circumstances for these patients.

Methods and results: We prospectively followed 51 patients with ICDs for up to 18 months to longitudinally assess in terms of (1) advance care planning, (2) health status, (3) healthcare utilization, and (4) end-of-life circumstances through quarterly phone interviews and electronic medical record review. The mean age was 71.1±8.3, 74.5% were men, and 19.6% were non-white. Congestive heart failure was predominant (82.4%), as was chronic kidney disease (92%). At baseline, a total of 12% of subjects met criteria for major depression, and 78.4% met criteria for mild cognitive impairment. From this initial study cohort, 76% survived to 18 months and completed all follow-up interviews, 18% died, and 19% withdrew or were lost to follow-up. Though living will completion and healthcare proxy assignment were common (cumulative outcome at 18 months 88% and 98%, respectively), discussions of prognosis were uncommon (baseline, 9.8%; by 18 months, 22.7%), as were conversations regarding ICD deactivation (baseline, 15.7%; by 18 months, 25.5%). Five decedents with available data received shocks in the days immediately prior to death, including 3 of whom ultimately had their ICDs deactivated prior to death.

Conclusions: We demonstrated the feasibility of prospective enrollment and follow-up of older, vulnerable ICD patients. Early findings suggest a high burden of cognitive and psychological impairment, poor communication with providers, and frequent shocks at the end of life. These findings will inform the design of a larger cohort study designed to further explore the experiences of living and dying with an ICD in this important patient population.

Keywords: end‐of‐life care; health services research; implantable cardioverter‐defibrillator; outcomes research.

Figure 1

Study flow from derivation of the subject cohort through study completion. Reasons for ineligibility not were not mutually exclusive. All subjects who withdrew or were lost to follow‐up for interviews were still followed by electronic medical record review.

Figure 2

Distribution of scores according to the Katz Activity of Daily Living (A) and Lawton Instrumental Activities of Daily Living (B) scales among patients with implantable cardioverter‐defibrillators. For both scales, higher scores indicate a greater number of activities for which the patients reported impairment or required assistance. ADL indicates activity of daily living; IADL, instrumental activities of daily living.