Cleveland, OH - A terminal illness was identified in about a third of patients in a recent series of implantable cardioverter defibrillator (ICD) recipients, all of whom elected to have their device's shock function turned off to avoid unwelcome "resuscitation" in the event of a life-threatening arrhythmia [1].

The patients had been under the regular care and counsel of a multidisciplinary team that included experts in end-of-life issues who were vigilant about identifying terminal conditions and put ICD withdrawal among discussed options for palliative treatment, described a report in the October 2006 issue of the American Journal of Medicine. They were part of group of 63 ICD recipients who had been followed by the team and died over the decade preceding February 2004, before the explosion in primary-prevention ICD use in patients with LV systolic dysfunction.

With the number of ICD implantations climbing sharply higher, fewer patients are followed by cardiac electrophysiologists and many are living longer than past generations of device recipients, observed lead author Dr William R Lewis (MetroHealth Medical Center, Cleveland, OH). Many more are living long enough, in fact, to develop end-stage heart failure, cancer, chronic obstructive pulmonary disease (COPD), or other terminal diseases that could make them want to avoid protection from sudden death, he told heartwire.

Although many ICD recipients lead fairly normal lives despite their indication for a device, "we do approach them about the fact that at some point in their life, they may develop an illness that requires that we discuss whether to turn the defibrillator off or not," according to Lewis. Under his center's multidisciplinary care plan for ICD recipients, he said, the patient's overall health is watched carefully and the subject of ICD withdrawal is revisited later as necessary.

Patients have responded "very positively" to this approach, Lewis said, "especially when they get to the point when the end-of-life issues are starting to be made. They're appreciative that they've been well informed."

He said his group aimed their report at a broad-based rather than a cardiology-specific journal so it would be more likely to reach general cardiologists and general internists. "We think they are the ones who are going to end up taking care of the majority of patients with ICDs" and need to incorporate the device into their dialog with patients about end-of-life issues, said Lewis, who called it "a very neglected area of medicine."

In the group's series, only 5% of the 20 patients identified with a terminal condition died of an acute event such as sudden cardiac death or MI. The cause of death was unknown in another 5% and in the remaining 85% was judged to be the terminal illness, which was predominantly COPD, end-stage HF, or cancer.

In contrast, acute events were documented in 19% of the 43 patients without diagnosed terminal conditions and suspected, based on conversations with family members, in another 53%, according to Lewis and colleagues. A chronic disease was the cause of death in 21% of this group.

"These patients had a more acute and unpredictable disease course; thus, there was little time for counseling before death to allow shock withdrawal to be considered," they write.

Although some patients ask to have pacing withdrawn along with the device's shock capability, "our argument is that pacing is more of a comfort-care issue," according to Lewis. Patients who are pacemaker-dependent would be "very uncomfortable" living with their bradycardia, he said, and at increased risk for worsened LV function as well as injuries related to syncope.

In the current series, the group writes, the time to death after shock-therapy withdrawal didn't differ significantly between the six pacemaker-dependent patients and the 14 others (46 and 44 days, respectively), suggesting that "continuing pacing therapies in pacemaker-dependent individuals did not artificially prolong life."