In the Context of the End of Life

Current Pacemaker and Defibrillator Therapy by Prof. Dr. med. Hans-Joachim Trappe, Prof. Dr. med. Jan Gummert in Heft 21/2011

The article by Trappe and Gummert was well worth reading, but in our opinion it would have been useful to focus briefly on the existing recommendations for handling internal cardioverter defibrillators (ICDs) in the context of the end of life.

In chronic underlying terminal diseases, repeated and sustained internal defibrillation may lead to extremely painful events during an otherwise calm dying process that constitute a genuine “shock” for patients and relatives, in the truest sense of the word, which prevents the patient from dying naturally and peacefully (1). Awareness of this problem is currently not as widespread as would be desirable (1, 2).

Leading institutions (among others, the European Heart Rhythm Association/American College of Cardiology; American Geriatrics Society; American Academy of Hospice and Palliative Medicine, American Heart Association und Heart Rhythm Society) in their consensus statements (1, 2) therefore recommend not to implant an ICD without providing extensive information (and documentation) about the problems potentially arising at the end of life.

In addition to many other recommendations, deactivation of the ICD is actively recommended as the minimum standard (1) if:

a) A so called DNR (do not resuscitate—in the absence of any medical indication) order exists, or

b) The treatment aims primarily to maintain a patient’s quality of life.

DOI: 10.3238/arztebl.2011.0686a

Dr. med. Jan Gaertner
Dr. med. Steffen Simon
Prof. Dr. med. Raymond Voltz
Zentrum für Palliativmedizin

Universitätsklinikum Köln
Centrum für integrierte Onkologie (CIO) Köln Bonn

Zentrum für klinische Studien Köln, BMBF 01KN0706

References

1. Trappe HJ, Gummert J: Current pacemaker and defibrillator therapy. Dtsch Arztebl Int 2011; 108(21): 372–80.

2. Padeletti L, Arnar DO, Boncinelli L, et al.: EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy. Europace 2010; 12(10): 1480–9.

3. Lampert R, Hayes DL, Annas GJ, et al.: American College of Cardiology. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 2010; 7(7): 1008–26.