Romanò Massimo, Piga Maria Antonella, Bertona Roberta, Negro Roberto, Ruggeri Chiara, Zorzoli Federica, Villani Rosvaldo
Centro Universitario Interdipartimentale di Ricerca in Cure Palliative, Università degli Studi, Milano - S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
Centro Universitario Interdipartimentale di Ricerca in Cure Palliative, Università degli Studi, Milano - Istituto di Medicina Legale, Università degli Studi, Milano.
G Ital Cardiol (Rome). 2017 Feb;18(2):139-149. doi: 10.1714/2663.27299.
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.
全球范围内植入式心脏复律除颤器的数量不断增加，其主要适应证是心脏性猝死的一级预防。在随访期间，患者可能死于潜在心脏病的进展或非心律失常原因，如恶性肿瘤、痴呆和肺部疾病，直到生命的最后几天或几周才接受适当的电击治疗。这些情况大约发生在30%的患者中，主要发生在死亡前的最后24小时。在这种情况下，不适当甚至适当的电击治疗都无法延长生命，反而可能只会导致疼痛和生活质量下降。因此，尽早与患者及其亲属讨论在生命末期停用植入式心脏复律除颤器（ICD）显得很重要。本综述的目的是概述ICD停用的伦理、临床和沟通问题，特别关注患者的意愿。文中指出，患者未充分了解ICD的风险和益处以及ICD停用的选择；医生不习惯与患者讨论临终决策的话题。如国际指南所建议，完整的信息必须成为ICD植入前当前知情同意的一部分，并应在随访期间更新，尤其要关注心力衰竭患者的预后和预先指示。
