Ethical and legal perspective of implantable cardioverter defibrillator deactivation or implantable cardioverter defibrillator generator replacement in the elderly

Abstract

ICD deactivation and nonreplacement are unavoidable issues that require clarity for meaningful and ethical implementation. This is an ongoing process.

2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

“…OKRESU ŻYCIA U pacjentów w fazie terminalnej często występują stany sprzyjające zaburzeniom rytmu (hipoksja, ból oraz zaburzenia elektrolitowe) i nawet u 20% osób z ICD dochodzi do wyłado-wania urządzenia w ostatnich tygodniach życia [805,807,808].…”

“…Należy uwzględniać indywidualne życzenia pacjenta, honorując zarówno świadomą zgodę, jak i świado-mą odmowę. Jeżeli pacjenci nie są w stanie podjąć tej decyzji samodzielnie, to należy wysłuchać opinii członka rodziny lub osoby podejmującej decyzje w zastępstwie pacjenta bądź też postąpić zgodnie z oświadczeniem woli pacjenta, jeżeli takie zostało sporządzone [805,808,809].…”

Refusing Implantable Cardioverter Defibrillator (ICD) Replacement in Elderly Persons-The Same as Giving Up Life: A Qualitative Study

“…There is increasing focus on respecting the patient's rights and obligation to actively participate in decision making when end of life is near. Accordingly, it seems relevant to consider the intention and purpose of an ICD within this population . In older persons with an ICD at the end of life there is a risk of shock therapy, which might cause a painful and undignified death, in addition to preventing the patient from dying in a fast way due to fatal ventricular arrhythmia .…”

“…The patient's right to renounce ICD treatment when end of life is near, and by that the possibility to die a dignified and peaceful death, is discussed in scientific literature. Two important issues arise: Deactivation of the shock function and ICD replacement . These challenge the existing technological paradigm in Western countries, because death has become individualized, a taboo that is being repressed and connected to fear and thereby “forbidden.”…”

“…Utilization of this intervention has increased in the Western world; more than 20% of ICD devices are implanted in elderly ≥80 years of age . There is an increased use of ICDs in the elderly; 42% of these patients are above 70 years and 12.4% are older than 80 years …”