Ethical challenges of deactivation of cardiac devices in advanced heart failure.
Ethical challenges of deactivation of cardiac devices in advanced heart failure.
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DOI：
10.1007/s11897-014-0194-8
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发表时间：
2014-06-01
影响因子：
--
通讯作者：
Albar, Mohammed Ali
中科院分区：
文献类型：
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作者：
Chamsi-Pasha, Hassan;Chamsi-Pasha, Mohammed A;Albar, Mohammed Ali
全世界有超过2300万成年人患有心力衰竭（HF）。尽管心力衰竭诊断后的生存率随着时间的推移而提高，但心力衰竭的死亡率仍然很高。在生命的尽头，慢性HF患者的症状通常会越来越严重，并且还可能患有其他限制生命的合并症。多项试验表明，在心肌病和室性心律失常患者中使用植入式心律转复除颤器（ICD）可明显降低死亡率。然而，植入ICD的患者可能被剥夺了心脏性猝死的机会，而是致力于缓慢的终末衰退，频繁的DC电击可能是痛苦的，并降低了生活质量，极大地增加了他们及其家人在此期间的痛苦。虽然植入ICD的患者通常会接受有关ICD受益的咨询，但他们对器械停用的选择以及相关的伦理和法律的影响了解甚少。停用ICD或不进行发生器更换是法律的和道德的，并得到大西洋两岸指导方针的支持。病人的自主权是最重要的，没有病人致力于他们不再希望接受的任何治疗。左心室辅助装置（LVAD）最初被用作等待心脏移植患者的桥梁，但目前已被植入作为对最佳药物治疗无效且不适合心脏移植的终末期心力衰竭患者的目的地治疗（DT）。LVAD启动和停用的决策过程在伦理和临床上变得越来越具有挑战性，尤其是对于老年患者。
More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.