Forensic, legal, and clinical aspects of deaths associated with implanted cardiac devices

Abstract

As the population ages, the prevalence of heart failure and individuals wearing an implanted cardiac device is increasing. The combination of different underlying pathophysiologies and (the combination of) implanted cardiac devices can become a challenge with regard to the determination of cause and manner of death in such individuals. Additionally, heart disease is frequently associated with mental disease, ranging from anxiety and depression to suicidality and suicide (attempts). At the same time, the correct diagnosis of cause and manner of death is the basis for quality assurance, further therapeutic advances, legal safety, and suicide prevention. By that, an interdisciplinary field between legal medicine, clinicians, and law enforcement opens up. In this field, the different participants can simultaneously benefit from and need each other. For example, legal medicine experts need investigatory results and clinical expertise for the interpretation of readout data of implanted cardiac devices in order to correctly determine the cause of death. A correctly determined cause of death can assist law enforcement and help clinicians to further improve various therapeutic approaches based on correct mortality data collection. In addition, it is the basis for identification of suicides of device carriers, allowing psychological and psychiatric experts to better understand the burden of mental disease in this particular cohort. Against this interdisciplinary background, this manuscript summarizes information about psychiatric comorbidities and suicidality while being on a device. Thereby, basic information on complications and malfunctions of implanted cardiac devices, device-associated deaths with particular emphasis on device manipulation is displayed as basic information needed for correct determination of the cause of death. Also, legal and ethical issues in this field are outlined. The final result is a proposal of an interdisciplinary assessment workflow for a conjoint approach to improve the diagnosis of deaths associated with implanted cardiac devices. It will allow for a differentiation between an individual who died with or due to the device.

Keywords: cause of death; end stage heart disease; ethics; implanted cardiac devices; left ventricular assist device; mental co-morbidity in cardiac disease.

Figure 1

Example for potential consequences of loss of function of different cardiac devices. For PM, LVAD, and CRT-D, different potential scenarios starting with a loss of function of the respective device are displayed. It is highlighted that although the starting point is the same in different scenarios, each scenario reaches a different endpoint and in some cases may even reach different endpoints within a given scenario. CRT-D, cardiac resynchronization – defibrillator; LVAD, left ventricular assist device; PM, pacemaker.

Figure 2

Assessment workflow for deaths in association with implanted cardiac devices. The selection of the different shapes was done aligned to what is known from entity-relationship models (i.e., the rectangles display an entity, ellipses represent attributes, and the diamond shape indicates a relationship). (α) The preparation technique should be adapted depending on the investigative questions and the encountered devices. So, for example if there is an CRT-D system and there is the question for lead-associated complications, the preparation should be done with special care for the venous system to be able to distinguish between antemortem findings and preparation-associated artifacts and to avoid dislocation of potentially adherent thrombi or vegetations. (β) Especially if there is a known complex pathophysiology underlying the IcarDs, one should consider a clinical consultation for conjoint interpretation of both autoptic findings together with the readout data and the known clinical history. The conjoint approach facilitates the integration of as many as possible information to a cause and by that manner of death. At this point it must be pointed out that the scenario “clinical manipulation” is somehow ambiguous. Depending on the underlying disease, the encountered IcarD or combination of IcarDs, turning off an IcarD can at least accelerate the occurrence of death (compare ethical and legal aspects of clinical IcarD manipulation in end-of-life decision). CRT-D, Cardiac Resynchronization Therapy – Defibrillator; IcarD, implanted cardiac device.