title: [Implantable cardioverter-defibrillator deactivation at the end of life: ethical, clinical and communication issues].
abstract: The number of cardioverter-defibrillator implants is increasing worldwide, with the main indication being primary prevention of sudden cardiac death. During the follow-up, patients may die from progression of their underlying heart disease or from nonarrhythmic causes, such as malignancies, dementia and lung disease, without receiving 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 hours before death. In this case, inappropriate and even appropriate shock deliveries can no longer prolong life and may simply lead to pain and reduced quality of life. Therefore, it appears important to discuss early with the patients and their relatives about deactivation of the implantable cardioverter-defibrillator (ICD) at the end of life.The goal of this review is to provide an overview of the ethical, clinical and communication issues of ICD deactivation, with a special focus on patients' wishes. It is outlined that patients are not adequately informed about risks and benefits of ICD and the option of ICD deactivation; the doctors are not used to discuss with the patients the topics of end-of-life decisions. Complete information must be part of current informed consent before ICD implantation and should be updated during the follow-up, with special attention to patients with heart failure in relation to their prognosis and advance directives, as suggested by international guidelines.
authors.affiliation: Centro Universitario Interdipartimentale di Ricerca in Cure Palliative, Università degli Studi, Milano - S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
authors.forename: Massimo
authors.initials: M
authors.lastname: Romanò
authors.affiliation: Centro Universitario Interdipartimentale di Ricerca in Cure Palliative, Università degli Studi, Milano - Istituto di Medicina Legale, Università degli Studi, Milano.
authors.forename: Maria Antonella
authors.initials: MA
authors.lastname: Piga
authors.affiliation: S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
authors.forename: Roberta
authors.initials: R
authors.lastname: Bertona
authors.affiliation: S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
authors.forename: Roberto
authors.initials: R
authors.lastname: Negro
authors.affiliation: S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
authors.forename: Chiara
authors.initials: C
authors.lastname: Ruggeri
authors.affiliation: S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
authors.forename: Federica
authors.initials: F
authors.lastname: Zorzoli
authors.affiliation: S.C. Cardiologia, Ospedale di Vigevano, ASST della Provincia di Pavia.
authors.forename: Rosvaldo
authors.initials: R
authors.lastname: Villani
mesh_terms: D001291:Attitude of Health Personnel; D017147:Defibrillators, Implantable / Q000941:ethics*; D006801:Humans; D007558:Italy; D010353:Patient Education as Topic; D013727:Terminal Care / Q000941:ethics* / Q000331:legislation & jurisprudence; D028761:Withholding Treatment / Q000941:ethics* / Q000331:legislation & jurisprudence