Aligning goals with care: Advance directives in older adults with implantable cardioverter-defibrillators

BACKGROUND

Patients ≥80 with implantable cardioverter-defibrillators (ICDs) have high rates of hospitalization and mortality, yet few have documented advance directives. We sought to determine the prevalence of advance directives in adults ≥80 years with ICDs, focusing on those with frailty and cognitive impairment.

METHODS

Prospective cohort study (July 2016-May 2019) in an electrophysiology clinic. Presence of advance directives (health care proxies [HCP] and living wills [LW], or medical orders for life-sustaining treatment [MOLST]) was determined by medical record review. Frailty and cognitive impairment were screened using 4-m gait speed and Mini-Cog.

RESULTS

77 Veterans were evaluated. Mean age 84 years, 100% male, 70% frail. Overall, 52 (68%) had an HCP and 37 (48%) had a LW/MOLST. Of 67 with cognitive testing, 36% were impaired. HCP documentation was similar among frail and non-frail (69% vs. 65%). LW/MOLST was more prevalent among frail versus non-frail (52% vs. 39%). There was no difference in HCP documentation by cognitive status (67%). A LW/MOLST was more frequent for cognitively impaired versus non-impaired (50% vs. 42%). Among 19 Veterans who were frail and cognitively impaired, 14 (74%) had an HCP and 11 (58%) had a LW/MOLST.

CONCLUSIONS

Most Veterans had a documented advance directive, but a significant minority did not. Simple frailty and cognitive screening tools can rapidly identify patients for whom discussion of advance directives is especially important.

Shared decision-making for older adults with cardiovascular disease

Shared decision‐making is appropriate for clinical decisions involving multiple reasonable options, which occur frequently in the cardiovascular care of older adults. The process includes the communication of relevant factual information between the patient and the clinician, elicitation of patient preferences, and a mutual agreement on the best course of action to meet the patient's personal goals. For older adults, there are common challenges and considerations with regard to shared decision‐making, some of which (eg, cognitive impairment) may be biologically linked to cardiovascular disease. There are tools designed to facilitate the shared decision‐making process, known as decision aids, which are broadly effective although have shortcomings when applied to older adults. Novel approaches in clinical research and health systems changes will go some way toward improving shared decision‐making for older adults, but the greatest scope for improvement may be within the grass roots areas of communication skills, interdisciplinary teamwork, and simply asking our patients what matters most.