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Published on: February 28, 2012
Implantable cardioverter defibrillator explantation upon patient request: Clinical and ethical considerations
1Organizing Committee Master in Palliative Care, University of Milan, Milan, Italy.
Insights
A young patient with hypertrophic obstructive cardiomyopathy successfully had their Implantable Cardioverter Defibrillator (ICD) removed after 7 years due to psychological distress. This case highlights patient autonomy and shared decision-making in cardiac device management.
Area of Science:
- Cardiology
- Medical Ethics
- Psychology
Background:
- Implantable Cardioverter Defibrillators (ICDs) are crucial for preventing sudden cardiac death (SCD) in high-risk patients.
- However, ICDs can cause significant psychological distress and reduced quality of life, particularly in younger individuals.
- ICD removal is rare and presents complex clinical and ethical challenges.
Purpose of the Study:
- To discuss the rare case of ICD explantation in a young patient with hypertrophic obstructive cardiomyopathy due to psychological intolerance.
- To explore the ethical and clinical considerations surrounding patient-requested ICD removal.
- To emphasize the importance of patient autonomy and shared decision-making in device management.
Main Methods:
- Case report of a young patient with hypertrophic obstructive cardiomyopathy who underwent ICD implantation for primary SCD prevention.
- The patient repeatedly requested ICD removal due to psychological device intolerance.
- Explantation was performed after extensive psychological evaluation and legal consent, 7 years post-implantation.
Main Results:
- The patient, who underwent ICD explantation 7 years after implantation, is alive and in good health.
- The explantation was facilitated by Italian law 219/2017, ensuring patient autonomy in medical treatment decisions.
- The case underscores the possibility of ICD removal under specific circumstances.
Conclusions:
- Patient-physician relationships should prioritize patient autonomy and respect individual experiences of illness.
- Shifting from a paternalistic to a patient-centered model ensures patient choices align with their values and life goals.
- Shared decision-making and decision aids enhance informed consent, fostering true partnership in patient care.
Background:
Implantable Cardioverter Defibrillator (ICD) implantation has significantly modified the natural history of patients at high risk of sudden cardiac death (SCD) in various types of heart diseases. However there is a high rate of psychological distress and reduced quality of life in patients with an ICD, more evident in younger individuals. The ICD removal upon patient request is a very rare event and causes many clinical and ethical issues.
Methods:
The article discusses the case of a young patient affected by hypertrophic obstructive cardiomyopathy, who underwent implantable cardioverter defibrillator (ICD) implantation as a primary prevention of sudden cardiac death (SCD). Two years after the implantation, the patient repeatedly requested removal of the ICD due to of a significant and untreatable psychological device intolerance.
Results:
Intervention became possible only after extensive psychological evaluation, which excluded specific pathology, and the ratification of Italian law 219/2017 on informed consent and advance directives, which guarantees the patient's independent decisions on current and future medical treatment. The explantation was performed 7 years after the implant. The patient is alive and in good health.
Conclusions:
The paper debates the issues related to establishing a patient-physician relationship based on respect for the patient's autonomy and experience of illness, in reference to principles such as beneficence and non-maleficence, and the conflicts that sometimes arise between them. If a paternalistic approach in the patient-physician relationship evolves into a patient-centered model, it is more certain that the patient's choice is realistically known and shared, and that it is consistent with the patient's values and life goals. The shared decision making (SDM) process and the use of pathology-specific decision aids are able to transform the informed consent tool, usually related to medical-legal issues, into an aid for true partnership between the patient and the medical care team.
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