Implantable cardiac device deactivation at the end of life

Abstract

Treatment of patients with heart failure is based on drugs, cardiac surgery and implantable cardiac devices to prevent sudden cardiac death (implantable cardioverter-defibrillator [ICD]), to reverse left ventricular dysfunction associated with left bundle branch block (cardiac resynchronization therapy) or mechanical circulatory support in more advanced phases of heart failure (left ventricular assist devices [LVAD]).During the follow-up, patients may die from progression of their underlying heart disease or from non-arrhythmic causes, such as malignancies, multi-organ failure, stroke, etc., without benefits by implanted devices. Patients implanted with ICD could die from non-arrhythmic causes, without 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 h before death. LVAD therapy may induce significant complications, such as infections, hemorrhagic stroke, thromboembolism, right ventricular failure. In these cases, inappropriate and even appropriate shock deliveries by ICD can no longer prolong life and may simply lead to pain and reduced quality of life, as well as LVAD may prolong life with painful distress due to complications. Therefore, it appears important to discuss early with the patients and their relatives about deactivation of ICD or LVAD at the end of life. The goal of this paper is to provide an overview of the ethical, clinical and communication issues of cardiac implanted device deactivation, with a special focus on issues associated with advance care planning, which require shared decision-making, including those related to end of life decisions (advance directives). Palliative care should be early implemented, particularly in patients with LVAD.