Cardiac Device Deactivation Remains a Much-Delayed (and Thorny) Topic

Shelley Wood

November 28, 2013

ROCHESTER, MN — A review of 150 patients who, by request, had their implanted electronic cardiac devices deactivated suggests that physicians and patients are not planning ahead or including their wishes regarding deactivation in their advance directives.

This is despite the fact that all but one of the patients in the analysis had a very poor or terminal prognosis at the time the device was deactivated. Strikingly, half of all deactivation requests were made by surrogates, not the patients themselves, often just days before the patient's death.

"Patients should be encouraged to execute advance directives with device-specific language to ensure that they receive care consistent with their preferences," Lillian C Buchhalter (Mayo Medical School, Rochester, MN) and colleagues write in this week's issue of JAMA Internal Medicine [1].

Among their other findings:

  • 135 of 150 devices were implantable cardioverter-defibrillators.

  • The majority (79%) underwent deactivation of tachycardia therapies only.

  • Most deactivations (55%) were carried out by nurses; 15% by industry-employed allied professionals.

  • Only one of 89 advance directives specifically mentioned the implanted device.

  • Median survival after device deactivation was just two days.

  • Consultation with a palliative-care practitioner was more common among patients who made the deactivation decision themselves.

The paper is accompanied by two commentaries: one coauthored by journalist Katy Butler, whose multiple-award–winning essay "What Broke My Father's Heart," published in the New York Times, chronicled her family's struggle to deactivate her ill and debilitated father's pacemaker [2].

The second commentary was coauthored by theheart.org blogger Dr John Mandrola, who has long spoken and written passionately on this topic [3].

Both commentaries address the discomfort many physicians feel around end-of-life discussions and offer recommendations as to how these discussions could be broached. As Butler and coauthor Dr Sunita Puri (Stanford University, Palo Alto, CA) write: "Improving the care of cardiac patients involves coupling technologic advancement with greater skill in communication. Far from being at odds, the two are symbiotic. As our population ages and cardiac devices grow ever more common, the quality of these conversations will vastly improve the quality of our patients' lives—and of their deaths."

Mandrola, with Dr Daniel D Matlock (University of Colorado School of Medicine, Aurora), put it even more bluntly: "It is now long past time to remove fear and ignorance from the end-of-life process. Achieving this fundamental task will not require new policies, reimbursement strategies, or routine specialty consultations. All it will take is humans respecting each other. It's about caring—the most rewarding part of medicine."

Buchhalter and the authors of the commentaries reported no conflict of interests. Disclosures for the study coauthors are listed in the paper.

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