Author + information
- Received May 7, 2019
- Revision received July 1, 2019
- Accepted July 8, 2019
- Published online September 23, 2019.
- Nathan E. Goldstein, MDa,b,∗ (, )@drnategoldstein,
- Harriet Mather, BMBCh, MSca,
- Karen McKendrick, MPHa,
- Laura P. Gelfman, MD, MPHa,b,
- Mathew D. Hutchinson, MDc,
- Rachel Lampert, MDd,
- Hannah I. Lipman, MD, MSe,f,
- Daniel D. Matlock, MD, MPHg,h,
- Jacob J. Strand, MDi,
- Keith M. Swetz, MA, MDj,
- Jill Kalman, MDk,
- Jean S. Kutner, MD, MSPHg,
- Sean Pinney, MDl and
- R. Sean Morrison, MDa,b
- aBrookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- bJames J. Peters Veterans Affairs Medical Center, Bronx, New York
- cDivision of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, Arizona
- dDepartment of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
- eHackensack University Medical Center, Hackensack, New Jersey
- fHackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
- gDivision of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- hVA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
- iDivision of General Internal Medicine, Department of Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
- jBirmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, Alabama
- kLenox Hill Hospital, Northwell Health, New York, New York
- lDivision of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- ↵∗Address for correspondence:
Dr. Nathan Goldstein, Department of Geriatrics and Palliative Medicine–Box 1070, Mount Sinai Medical Center, One Gustave Levy Place, New York, New York 10029.
Background Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function.
Objectives The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation.
Methods In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion.
Results A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. Secondary outcomes: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives.
Conclusions The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients’ severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744)
This work was supported by a grant from the National Heart, Lung, and Blood Institute (R01HL102084). Additional support was provided by the Claude D. Pepper Older Americans Independence Center at the Icahn School of Medicine at Mount Sinai (5P30AG028741). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Department of Veterans Affairs. Dr. Gelfman has received support from the National Institute on Aging (K23AG049930). Dr. Lampert has served on the Advisory Board of Medtronic; and has received research grants from Medtronic and Abbott/St. Jude Medical. Dr. Pinney has served as a consultant for Abbott, CareDx, and Medtronic; and has served on the Advisory Board of Procyrion. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Lynne Warner Stevenson, MD, MPH, served as Guest Associate Editor for this paper.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received May 7, 2019.
- Revision received July 1, 2019.
- Accepted July 8, 2019.
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