Withdrawing implantable defibrillator shock therapy in terminally ill patients.
OBJECTIVE
The purpose of this study is to review a multidisciplinary strategy used to identify patients with terminal illnesses and initiate withdrawal of implantable cardioverter defibrillator (ICD) shock therapy as part of a comprehensive comfort care approach. With indications for ICDs increasing, more patients are receiving devices. Once protected from an arrhythmic death, these patients may develop other terminal diseases such as cancer or congestive heart failure. It is appropriate to withdraw defibrillator shock therapy when such patients desire only comfort care.


METHODS
The charts of ICD patients who had died were reviewed. Two groups emerged: Group 1 (20) included patients whose defibrillator was turned off through the comprehensive comfort care approach. Group 2 (43) included patients whose clinical course was so rapid that the defibrillator was not turned off. Pacing therapy was not withdrawn in either group.


RESULTS
Defibrillator discharges, cause of death, and time from ICD discharge to death were compared. Group 2 patients died more acutely than Group 1. Group 1 experienced fewer shocks prior to death when compared to Group 2. Comparing pacemaker dependent and non-dependent patients, there was no difference in the time between therapy discontinuation and death.


CONCLUSIONS
This is the largest study to date to review the characteristics of patients with ICDs and terminal illness. Only one-third of terminally ill patients with ICDs were able to have shock therapy withdrawn as part of a comfort care strategy. These patients experienced fewer shocks in the final days of their illness.
Lewis
William R
WR
Heart and Vascular Center, MetroHealth Campus, Case Western Reserve University, Cleveland, Ohio 44109, USA. wlewis@metrohealth.org
Luebke
Donna L
DL
Johnson
Nancy J
NJ
Harrington
Michael D
MD
Costantini
Ottorino
O
Aulisio
Mark P
MP
D000368:Aged; D001145:Arrhythmias, Cardiac / Q000628:therapy; D002423:Cause of Death; D017147:Defibrillators, Implantable / Q000941:ethics*; D005260:Female; D006801:Humans; D008297:Male; D010166:Palliative Care / Q000941:ethics*; D016414:Resuscitation Orders; D012189:Retrospective Studies; D019452:Terminally Ill