In Reply

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

Prevention of sudden cardiac death by means of implantable defibrillators has been amply documented for more than 25 years (1). Because of the ageing population and an increasing expansion of ICD and/or resynchronization therapy, questions arise about patients’ quality of life and of how to handle ICD treatment at the end of life (2). Repeated ICD shocks are not only painful, but they may be traumatic for dying patients and their relatives, as well as for doctors and nursing staff. At the end of life it may be advisable to deactivate the device, especially as repeatedly triggered shocks in the prefinal stage are not unlikely. Goldstein et al investigated the circumstances of dying in 136 people with ICDs (3). They found that in only 27% of cases the doctors discussed deactivating the device with the patient, and only at a very late stage of their illness (3). It also became obvious that many doctors experienced a feeling of killing the patient by deactivating the ICD and were uncertain about the legal aspects of deactivation.

The fact that in recent statements about this problem a discussion with patients and relatives has been stipulated before ICD implantation—especially regarding the situation at the end of life—is to be welcomed. Equally welcome and worth supporting is the recommendation to deactivate the device in patients in whom resuscitation is not medically indicated or where the primary treatment objective is the patient’s quality of life.

It is therefore imperative to discuss the circumstances of dying for people with an ICD with patients, their relatives, their doctors, and their nursing staff, in order to enable dying without pain and with dignity, and to save relatives from experiencing additional trauma at the end of life.

DOI: 10.3238/arztebl.2011.0686b

Prof. Dr. med. Hans-Joachim Trappe

Medizinische Klinik II (Schwerpunkte Kardiologie und Angiologie)

Ruhr-Universität Bochum

Conflict of interest statement

All authors declare that no conflict of interest exists.

References

1. Trappe HJ: 25 Jahre Defibrillatortherapie in Deutschland. Was haben wir erreicht, was können wir noch erwarten? Kardiologe 2009; 5: 413–24.

2. Ladwig KH, Ronel J, Baumert J, Kolb C: Psychische Komorbidität und Lebensqualität bei Patienten mit implantierbarem Kardioverter/Defibrillator (ICD). Herzschr Elektrophys 2010; 21: 129–36.

3. Goldstein NE, Lampert R, Bradley E, Lynn J, Krumholz HM: Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med 2004; 141: 835–8.

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