Dr James N Kirkpatrick

Chicago, IL - Most patients have no idea what happens to their implantable cardiac devices after they die, a new survey shows [1]. Dr James N Kirkpatrick (University of Pennsylvania, Philadelphia) told a press conference at the American Heart Association 2006 Scientific Sessions that three quarters of those he questioned would agree to an advance directive—a so-called "device living will"—stipulating what they would like to happen to the device after their death.

However, they might then face a conflict between agreeing to have the device returned to the manufacturer to help improve future product reliability and donating it for use in developing countries—the two choices are mutually exclusive, he explained.

Advance directives would greatly help morticians in deciding what to do with the devices, he said. A previous survey of morticians by his group—reported at the American College of Cardiology meeting in March 2006—revealed that many of them did not know the options available either.

HRS advises returning devices to manufacturer

"If a patient dies, we don't know if it's due to device failure or something else," Kirkpatrick explained. "And we won't know what has happened if we don't analyze the devices. Removing them and returning them to industry could help improve product reliability," he said. Guidelines published last month by the Heart Rhythm Society Task Force [2] propose mandating that devices be removed and returned to the manufacturer after the death of a patient.

Currently in the US, the majority of devices are buried with the deceased. In the case of cremation, devices must be removed because of the risk of them exploding. Almost half of these are thrown away, and fewer than 20% are donated to charitable causes.

There is an option for a noninvasive examination of the device (without removing it), which will yield some information as to whether it malfunctioned, but probably not as much as if the device were taken out and analyzed, Kirkpatrick noted.

His previous survey of morticians revealed that they were willing and able to remove the devices as long as they had informed consent. "But we were amazed to find that the morticians had no clue that the manufacturers want the devices back or what to do with them. Conversely, industry representatives were surprised to find that no one knows they would like the devices back for analysis," he explained.

Manufacturers will carefully evaluate devices and store the information, but after that the device is stored or returned to the patient's family if they want it (it can be monogrammed with the initials of the deceased). Unfortunately, if devices are returned to the manufacturer they will not usually be donated to charity for use overseas (it is illegal to reuse such devices in the US), Kirkpatrick explained.

Conflict for the patients?

In their new survey, Kirkpatrick and colleagues interviewed 150 patients undergoing routine pacemaker or defibrillator interrogation, and asked them what they thought was done with the device after death.

"We didn't explain to the patients what the options were, we just asked them what they thought happened," he noted. Of the 150 respondents, 130 (87%) did not know what was done with the device, seven (5%) assumed devices were routinely removed, eight (5%) thought they were buried with the deceased, four (3%) believed they were recycled, and one (<1%) assumed they were routinely donated to charity.

When asked whether they would be willing to have their device interrogated after death, 123 (82%) said they would. Of these, 118 were willing to have it returned to the manufacturer; most said they would be prepared to sign a device advance directive stating so. Of the 118, 91% said they would be willing to have the device removed and donated for use in developing countries, and 79% said they would agree to donate it for use in pets.

But the fact that a device returned to the manufacturer cannot then be donated for use in developing countries "clearly produces a conflict" for patients deciding on their options, he acknowledged.

As reported previously by heartwire, there are two or three charitable organizations in the US that will take devices from morticians, check their battery life, check for malfunctions, and then send them on to be used in developing countries. For example, one organization in Montana sends around 2000 pacemakers to South America every year, where they are used in patients suffering from Chagas disease, Kirkpatrick noted.