Implantable cardioverter defibrillators in people dying with cancer: A SEER-Medicare analysis of ICD prevalence and association with aggressive end-of-life care

Abstract

Introduction: The shared risk profiles for cancer and heart disease suggest many individuals with cancer may have an implantable cardioverter defibrillator (ICD). ICDs can have dramatic cancer end-of-life care implications including painful and distressing shocks. ICD prevalence and association with aggressive end-of-life care among individuals with breast, colorectal, and pancreatic cancer was evaluated using the Surveillance, Epidemiology, and End Results-Medicare dataset.

Methods: A total of 37,306 Medicare beneficiaries aged ≥66 years with stage 3 or 4 cancer who died between 2005 and 2016 were identified. ICD prevalence, ICD-related care utilization that might present opportunities to discuss end-of-life implications and association with aggressive end-of-life care (>1 emergency department visit, intensive care unit admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive or life-extending procedures) in the last month of life was assessed using multivariable logistic regression.

Results: Among cancer decedents, 6% had an ICD. More individuals with an ICD (31%) died in the hospital than individuals without an ICD (25%; p < .001). Half (46%) of individuals with an ICD had device programming or interrogation visits that could be an opportunity for device discussion. In adjusted models, ICD presence was associated with higher odds of every indicator of aggressive end-of-life care other than chemotherapy.

Conclusion: Many older cancer decedents in the United States had an ICD, and those with ICDs received more aggressive care at the end of life. Results suggest there are opportunities to discuss ICD and goals of care, raise awareness and encourage shared decision-making for this population to ensure goal-concordant care, and improve end-of-life care quality.

Keywords: end‐of‐life care; implantable cardioverter defibrillator; multimorbidity; quality of life.

FIGURE 1

Receipt of aggressive end‐of‐life care in the last 30 days of life by presence of implantable cardioverter defibrillator (ICD) among individuals with breast, colorectal, and pancreatic cancer who died between 2005 and 2016.

FIGURE 2

Implantable cardioverter defibrillator–related health care utilization within six months of death among individuals with breast, colorectal, and pancreatic cancer who died between 2005 and 2016 and had an implantable cardioverter defibrillator (ICD).

FIGURE 3

Associations between having an implantable cardioverter defibrillator (ICD) and receipt of aggressive end‐of‐life care for individuals with breast, colorectal, or pancreatic cancer dying between 2005 and 2016. Chemotherapy is in the last two weeks of life; all other outcomes are in the last 30 days. Life‐extending procedure includes: ventilation, resuscitation, or feeding tubes. Invasive procedure includes: surgery requiring anesthesia, placement of arterial or central line, endoscopy, interventional radiology procedure, radiotherapy, or pelvic examination with tissue sampling. Models are adjusted for sex, cancer type, race/ethnicity, urbanicity, geographic region, age, year of diagnosis, time between diagnosis and death, Charlson score, census tract poverty, cancer stage, and marital status.