The Decisions,Interventions,and Goals in ImplaNtable Cardioverter-DefIbrillator TherapY (DIGNITY) Pilot Study

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. © 2017 the authors. published on behalf of the american heart association,inc.,by wiley.