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[Implantable cardioverter-defibrillator deactivation at the end of life: ethical, clinical and communication issues]
Massimo Romanò1, Maria Antonella Piga2, Roberta Bertona3
1Centro Universitario Interdipartimentale di Ricerca in Cure Palliative, Università degli Studi, Milano - S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
Insights
Discussing implantable cardioverter-defibrillator (ICD) deactivation at end-of-life is crucial. Patients need comprehensive information on ICD risks, benefits, and deactivation options to align care with their wishes and avoid unnecessary suffering.
Area of Science:
- Cardiology
- Medical Ethics
- Palliative Care
Background:
- Implantable cardioverter-defibrillator (ICD) implants are increasing globally for sudden cardiac death prevention.
- A significant percentage of patients die from non-arrhythmic causes, often experiencing shocks near end-of-life.
- These shocks may cause pain and reduce quality of life without prolonging survival.
Purpose of the Study:
- To review ethical, clinical, and communication aspects of ICD deactivation at end-of-life.
- To emphasize the importance of patient autonomy and informed decision-making.
- To highlight the need for better patient and physician communication regarding ICDs and deactivation.
Main Methods:
- Literature review focusing on ethical, clinical, and communication challenges.
- Analysis of patient information regarding ICDs and end-of-life options.
- Examination of physician communication practices related to deactivation decisions.
Main Results:
- Patients are often inadequately informed about ICD risks, benefits, and deactivation.
- Physicians lack experience in discussing end-of-life decisions and ICD deactivation with patients.
- Current informed consent processes and follow-up care do not sufficiently address deactivation wishes.
Conclusions:
- Early and comprehensive discussions about ICD deactivation are essential.
- Informed consent for ICD implantation must include detailed information on deactivation.
- Regular updates during follow-up, especially for heart failure patients, are necessary to respect patient wishes and advance directives.
Abstract:
The number of cardioverter-defibrillator implants is increasing worldwide, with the main indication being primary prevention of sudden cardiac death. During the follow-up, patients may die from progression of their underlying heart disease or from nonarrhythmic causes, such as malignancies, dementia and lung disease, without receiving appropriate shocks until the last few days or weeks of their life. These events occur roughly in 30% of patients, mainly in the last 24 hours before death. In this case, inappropriate and even appropriate shock deliveries can no longer prolong life and may simply lead to pain and reduced quality of life. Therefore, it appears important to discuss early with the patients and their relatives about deactivation of the implantable cardioverter-defibrillator (ICD) at the end of life.The goal of this review is to provide an overview of the ethical, clinical and communication issues of ICD deactivation, with a special focus on patients' wishes. It is outlined that patients are not adequately informed about risks and benefits of ICD and the option of ICD deactivation; the doctors are not used to discuss with the patients the topics of end-of-life decisions. Complete information must be part of current informed consent before ICD implantation and should be updated during the follow-up, with special attention to patients with heart failure in relation to their prognosis and advance directives, as suggested by international guidelines.