Gestione degli ICD/CRT a fine vita dei pazienti. Prof. Luigi Padeletti Università degli Studi di Firenze

Transcription

1 Gestione degli ICD/CRT a fine vita dei pazienti Prof. Luigi Padeletti Università degli Studi di Firenze

2 What would you do if you knew you had 6 months to live? How would you choose to spend your time? Would you be willing to try an experimental and risky therapy that might decrease your quality but increase your quantity of life? What would you do if you knew that your patient had 6 months to live despite current clinical stability? Would you tell him? Would you be more or less aggressive with treatment options? Circulation 2007

3 Beyond ethical dilemmas: improving the quality of end-of-life care in the intensive care unit Gordon D Rubenfeld and J Randall Curtis Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington Abstract Consensus guidelines on providing optimal end-of-life care in the intensive care unit (ICU) are important tools. However, despite 30 years of ethical discourse and consensus on many of the principles that guide end-of-life care in the ICU, care remains inadequate. Although consensus on the most challenging ethical aspects of some cases will remain elusive, this need not deter clinicians from engaging in practical quality improvement, best practice, and educational interventions to provide compassionate care to all critically ill patients, including those who ultimately die Crit Care 2003;7:11-13

4 End-of-life Content in Treatment Guidelines for Life-Limiting Diseases Kimberly R. Mast, Marybeth Salama, Gabriel K. Silverman, Robert M. Arnold University of Pittsburgh, Division of General Internal Medicine, Pennsylvania Objective: To assess the degree to which end-of-life care is integrated into nationally developed guidelines for chronic, noncurable, life-limiting diseases. nine chronic diseases (chronic obstructive pulmonary disease, end-stage liver disease, amyotrophic lateral sclerosis, congestive heart failure, dementia, cerebrovascular accident, end-stage renal disease, cancer [breast, colon, prostate, lung], and human immunodeficiency virus) Results: Only 14% of guidelines advised physicians to consider palliative care at a specific point in the disease course. Conclusion: Current national guidelines on nine chronic, life-limiting illnesses offer little guidance in end-of-life care issues despite a recent increase in attention to this aspect of medical care. J Palliat Med 2004; 7:

5 End-of-life care for the critically ill: A national intensive care unit survey* Nelson JE, Angus DC, Weissfeld LA, Puntillo KA, Danis M, Deal D, Levy MM, Cook DJ; for the Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project. OBJECTIVE: One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. SETTING: Six hundred intensive care units. PARTICIPANTS: A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States. CONCLUSIONS: Intensive care unit directors perceive important barriers to optimal endof-life care but also universally endorse many practical strategies for quality improvement. Crit Care Med 2006;34:1-7

6 Gibbs et al. Heart 2002

7 Results: Patients and families reported a wide range of end-of-life care preferences. None had discussed these with their clinicians, and none was aware of choices or alternatives in future care modalities, such as adopting a palliative approach. Patients and carers live with fear and anxiety, and are uninformed about the implications of their diagnosis. Cardiac staff confirmed that they rarely raise such issues with patients. Disease - and specialism - specific barriers to improving end-of-life care were identified. Selman et al. Heart 2007

8 EOL patients: reccomendations Improve attitude towards physician assisted death All patients with advanced progressive life-limiting illnesses should be given the opportunity to discuss prognosis, including life expectancy Ensure facts about the patient s clinical circumstances are correct Use good generic communications skills and establish rapport with the patient and family Be aware of cultural differences in information preferences and attitudes to discussing prognosis and dying Use appropriate language: use everyday terms, clear language and unambiguous words Provide honest and realistic information in a straightforward manner Collaborate within the multidisciplinary team to ensure consistency of information Encourage patients to share in decision making according to their desirered level of involvement

9 Discontinuing an Implantable Cardioverter Defibrillator as a Life-Sustaining Treatment Timothy E. Quill, MD, S. Serge Barold, MD and Bernard L. Sussman, MD The Case of Mr Wilson Mr.W. was a 67-year-old man with coronary artery disease, degenerative joint disease, osteoporosis, and emphysema who had been asking to have his ICD turned off for over 1 year. He did not want to commit suicide, but rather to have his ICD discontinued so that he could die what he hoped would be a sudden death from his underlying heart disease. After many discussions, his wife and children agreed that this was his decision to make. His cardiologist subsequently met with him, confirmed that his request was unwavering, and turned off the ICD 32 months after implantation. Mr W. died suddenly 3 weeks later. Am J Cardiol 1994

10 Discontinuing an Implantable Cardioverter Defibrillator as a Life-Sustaining Treatment Timothy E. Quill, MD, S. Serge Barold, MD and Bernard L. Sussman, MD The Case of Mr Wilson As illustred in the case presented, life-sustaining medical treatments can save and prolong meaningful life. They are also capable of indefinitely prolonging a life filled with progressive suffering and loss, thereby prolonging an agonizing death. The potential of medical technology to have such diametrically opposed effects requires that it be used with utmost care and respect for its effect on each person. Am J Cardiol 1994

11 Discontinuing an Implantable Cardioverter Defibrillator as a Life-Sustaining Treatment Timothy E. Quill, MD, S. Serge Barold, MD and Bernard L. Sussman, MD Proposed Guidelines of Discontinuing Life-Sustaining Treatment in Competent Patients 1. The patient s request must be rational and consistent 2. There must be full understanding of the patient s condiction 3. Alternatives should be fully explored and understood by the patient 4. Depression, or other disorders that distort judgement, should be excluded 5. Specific plans should be made for how to proceed once treatment is discontinued 6. A second opinion should be obtain Am J Cardiol 1994

12 Deactivating ICD As patients develop terminal disease, they may change their goals from prolongation of life to comfort care, and shocks no longer serve their purpose. In addition, these patients are more likely to develop hypoxia, sepsis, pain, and electrolyte disturbances, predisposing them to ventricular and supraventricular arrhythmias and, thus, more frequent shocks. With a patient s quality of life dependent on so many factors, the decision to withdraw shock therapy mandates as much careful consideration as the decision to initiate implantable defibrillator therapy. Lewis et al. The American Journal of Medicine 2006

13 Management of ICDs in End-of-Life Care Next of kin reported that clinicians discussed deactivation of ICD in only 27/100 cases (27%) Most discussions occurred in the last few days of life 27 patients received a shock in the last month of their life 8 patients (30%) received a shock in the minutes before death 9 patients (33%) had subsequent discussions about ICD deactivation and 6 chose to have ICD turned off Family decided to deactivate ICD in 21 cases and most deactivations occurred in days, hours, or minutes before death Goldstein NE et al Ann Intern med 2004; 141: 835-8

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18 Key principles of liberal democratic societies Respect for diversity of values and cultures Rights for all individuals to be considered as being of equal worth Protection of fundamental human rights

19 Patients With decision-making capacity (autonomous patients) Without decision-making capacity Minors Mature minors

20 ICD deactivation Shock defibrillator function Antitachycardia pacing Diagnostic and monitoring functions Avoid elective replacement ( consider pacing function)

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22 Predominant religous heritage in europe

23 Percentage of Europeans in each Member State who believe in some deity

24 The best seat for deciding ICD deactivation