Understanding veteran perspectives surrounding implantable cardioverter- defibrillator decision-making

Background In 2018, the Center for Medicare and Medicaid Services (CMS) mandated the use of evidence-based shared decision-making (SDM) tools for cardiovascular decisions, including implantable cardioverter defibrillator (ICD) implantation for primary prevention in patients with systolic heart failure. Military Veterans are a unique population with experiences including combat, and heightened rates of anxiety, depression and post-traumatic stress disorder. Understanding Veteran perspectives on ICD decision-making processes is necessary to inform the Veteran Health Administration's (VHA) ICD care model. Study objective To understand factors influencing Veterans' ICD decision-making, semi-structured interviews were conducted with Veteran patients with an ICD (Implanters), those referred for consideration (Deliberators), and those who declined (Decliners). Methods Interviews explored experiences with being offered an ICD, understanding of the device, and factors influencing personal decisions. Data were analyzed using content and thematic analysis. Results Interviews with 13 participants revealed four primary themes that guided ICD decision-making: (1) desire for information and involvement in personal decisions, (2) quality of life values, (3) views of spirituality (4) Decliners and Deliberators accepted natural death and expressed desire to not intervene medically to prolong life. Participants valued consultation with providers and personal networks, yet ultimately prioritized autonomy. The role of mental health experiences and cohort-level differences on decision-making was inconclusive. Conclusion Participants' ICD implantation decision-making were influenced by considerations around quality of life, spiritual beliefs, and reluctance to invasively interfere with disease progression. These insights highlight the importance of personalized patient-provider interactions and the need for decision-support tools tailored to VHA Veteran care.