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Implantierbarer Kardioverter-Defibrillator am Ende des Lebens

Implantable cardioverter-defibrillator at the end of life

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Zusammenfassung

Am Lebensende kommt es regelhaft zu bradykarden oder tachykarden Arrhythmien. Implantierbare Kardioverter-Defibrillatoren (ICD) reagieren darauf mit antibradykardem oder antitachykarden Pacing, welches für den Sterbenden nicht mit Missempfindungen verbunden ist. Dagegen ist die Auslösung eines Schocks sehr schmerzhaft. Daher müssen Schocks in der Terminalphase abgeschaltet werden, wozu Hausärzte, Allgemeininternisten und Notärzte in aller Regel nicht in der Lage sind. Die Inaktivierung eines Defibrillators ist nach einem Urteil des Bundesgerichtshofs weder mit Euthanasie noch Sterbehilfe gleichzusetzen, sondern gestattet, dass der Patient in Frieden und ohne vermeidbare Schmerzen an seiner Grunderkrankung versterben kann. Die Inaktivierung der Schockalgorithmen sollte mit Patienten und Angehörigen daher frühzeitig, am besten bereits vor der Erstimplantation des Defibrillators, besprochen werden. Der konkrete Zeitpunkt einer Inaktivierung des Defibrillators am Lebensende ist eine Einzelfallentscheidung und bislang nicht präzise definiert. Notärzte sollten mit einem Magneten und der notwendigen Sachkenntnis ausgerüstet werden, um in der Terminalphase des Lebens den Defibrillator inaktivieren zu können. Der Wunsch des Patienten hat Priorität und sollte in einer Patientenverfügung rasch verfügbar sein. Der Arzt ist jedoch selbst nicht verpflichtet, jedem Wunsch des Patienten nachzukommen. Solange eine juristische Harmonisierung der Europäischen Union aussteht und keine einheitliche Gesetzgebung zu diesen Fragen enthält, sind Empfehlungen für Deutschland erforderlich.

Abstract

Brady- and tachyarrhythmias at the end of life are common observations. Implantable cardioverter–defibrillators answer with antibrady and antitachycardia pacing, which will not be associated with any complaints of the dying patient. In contrast, defibrillation and cardioversion shocks are extremely painful. Therefore shocks should be inactivated at the end of life. Family doctors, internists, emergency physicians and paramedics are unable to inactivate shocks. Deactivation of shocks at the end of life is not comparable to euthanasia or assisted suicide, but allow the patient to die at the end of an uncurable endstage disease. Deactivation of shocks should be discussed with the patient before initial implantation of the devices. The precise moment of the inactivation at the end of life should be discussed with patients and relatives. There is no common recommendation for the time schedule of this decision; therefore it should be based on the individual situation of the patient. Emergency health care physicians need magnets and sufficient information to inactivate defibrillators. The wishes of the patient have priority in the decision process and should be written in the patient's advance directive, which must be available in the final situation. However the physician must not necessarily follow every wish of the patient. As long as the laws in the European Union are not uniform, German recommendations are needed.

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Authors and Affiliations

  1. Abt. Kardiologie & Angiologie, Dept. Innere Medizin, Neurologie und Dermatologie, Universität Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland

    D. Pfeiffer, A. Hagendorff, C. Kühne, S. Reinhardt & N. Klein

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  1. D. Pfeiffer
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D. Pfeiffer, N. Klein, C. Kühne, S. Reinhardt und A. Hagendorff geben an, dass kein Interessenkonflikt besteht.

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Pfeiffer, D., Hagendorff, A., Kühne, C. et al. Implantierbarer Kardioverter-Defibrillator am Ende des Lebens. Herzschr Elektrophys 26, 134–140 (2015). https://doi.org/10.1007/s00399-015-0366-6

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