End-of-life care more aggressive for cancer patients with defibrillators
Study suggests providers should discuss treatment preferences with terminal patients who have heart devices, UTSW researchers say
DALLAS – Jan. 08, 2025 – Patients with advanced cancer who also had cardiac defibrillators were more likely than those without these implants to receive aggressive end-of-life care, a team led by UT Southwestern Medical Center researchers found in a new study. The findings, published in Cancer, could help physicians guide patients in this growing population toward care that better matches their goals.
“We know that many people who have cancer are also dealing with other medical problems concurrently, including heart arrhythmias,” said Megan Mullins, Ph.D., M.P.H., Assistant Professor in the Peter O’Donnell Jr. School of Public Health, the Harold C. Simmons Comprehensive Cancer Center, and the Department of Internal Medicine. “By putting these heart devices on cancer specialists’ radars, we can help them start having conversations with patients who have them to make sure their end-of-life care matches their stated wishes.”
Implantable cardioverter defibrillators (ICDs) sense abnormal heart rhythms and deliver an electric shock to reset heartbeats into a normal pattern. Although ICDs can be lifesaving, the shocks they deliver can be painful and traumatic – described as being kicked by a horse or punched in the chest. Because the heart stops at the end of life, Dr. Mullins added, it’s critical for doctors caring for terminal cancer patients who have ICDs to help them manage their devices – including the possibility of deactivating them – so they don’t suffer unnecessarily.
To assess end-of-life care for cancer patients with ICDs, Dr. Mullins and her colleagues used combined data from Surveillance, Epidemiology, and End Results (SEER) – a database that holds information from 18 population-based cancer registries – and Medicare to identify 37,306 patients ages 66 and older who died from advanced breast, colorectal, or pancreatic cancers between 2005 and 2016. Using billing codes, they searched for patients in this group who also had ICDs and compared care at the end of life for those who did and didn’t have these devices. Most individuals with ICDs had them implanted before their cancer diagnosis.
The findings showed that about 6% of patients with advanced cancer also had ICDs. However, significantly more of the ICD patients received aggressive care during the last month of their lives compared to those without these devices. Those with ICDs were more likely to have died in the hospital; received a life-extending or invasive procedure such as ventilation, resuscitation, a feeding tube, surgery requiring anesthesia, placement of an arterial or central line, endoscopy, or an interventional radiology procedure; or been hospitalized, which also included more than one emergency department visit or any intensive care unit admission. Each of these measures is an indicator of lower quality care because they commonly result from poor pain and symptom management and late or absent end-of-life conversations between patients and health care providers, Dr. Mullins said.
She and her team also found that nearly half of those with ICDs had at least one visit to a health care provider specifically about their devices within six months of their deaths, mostly for programming, testing, or monitoring. These visits could serve as opportunities for doctors to help patients discuss their end-of-life goals and preferences, Dr. Mullins said.
She added that future research will focus on why patients with ICDs are more likely to receive aggressive end-of-life care. In the meantime, UTSW cardiologists, including study co-author Melanie Sulistio, M.D., Professor of Internal Medicine in the Division of Cardiology, have initiatives underway to improve patients’ understanding of the implications of their devices and communicate their end-of-life preferences to loved ones and patient care providers.
Other UTSW researchers who contributed to this study include senior author Sandi L. Pruitt, Ph.D., M.P.H., Professor in the O’Donnell School of Public Health and Associate Director of Community Outreach and Engagement in the Simmons Cancer Center; Kathryn Shahan, M.P.H., Population Science Data Analyst in the O’Donnell School of Public Health; Vlad G. Zaha, M.D., Ph.D., Associate Professor of Internal Medicine; Rachna Goswami, M.D., M.P.H., Assistant Professor of Internal Medicine; and David E. Gerber, M.D., Professor of Internal Medicine and co-Director of the Office of Education and Training in the Simmons Cancer Center. Drs. Pruitt, Zaha, and Gerber are members of the Simmons Cancer Center.
This study was funded by the Texas Health Resources Clinical Scholar Program, the National Cancer Institute (NCI) (R01CA229834), and the NCI Cancer Center Support Grant (P30CA142543).
About UT Southwestern Medical Center
UT Southwestern, one of the nation’s premier academic medical centers, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty members have received six Nobel Prizes and include 25 members of the National Academy of Sciences, 24 members of the National Academy of Medicine, and 14 Howard Hughes Medical Institute Investigators. The full-time faculty of more than 3,200 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in more than 80 specialties to more than 120,000 hospitalized patients, more than 360,000 emergency room cases, and oversee nearly 5 million outpatient visits a year.