Der chronisch kritisch kranke Patient aus der Perspektive des Kardiologen

Leitthema

Zusammenfassung

Die Prognose der chronischen und akuten Herzinsuffizienz hat sich in den vergangenen Jahren stetig verbessert. Viele Patienten entwickeln eine fortgeschrittene chronische Herzinsuffizienz gekennzeichnet durch Verschlechterung der Symptome, häufige notfallmäßige Krankenhausaufnahmen bei akuter Dekompensation, rhythmogene Komplikationen sowie Verkürzung der Lebensdauer. Die medikamentöse Therapie wird heute durch die Möglichkeiten der interventionellen Kardiologie, einer differenzierten Schrittmachertherapie, minimal-invasiver Herzklappeneingriffe und der mechanischen Kreislaufunterstützung als Alternative zur Herztransplantation ergänzt, erweitert und optimiert. Die medizinische Indikation und der Patientenwille sind Grundvoraussetzungen der Umsetzung klar formulierter Behandlungsziele. Bei nicht einwilligungsfähigen Patienten bringt der juristischen Stellvertreter den zuvor geäußerten oder mutmaßlichen Patientenwillen zur Geltung. Die Möglichkeiten der modernen mechanischen Kreislaufunterstützung eröffnen neue Perspektiven, werfen aber auch bisher nicht gelöste ethische Fragen zur Indikation auch zur Terminierung dieser Systeme auf. Das gilt in gleicher Weise für die ubiquitär verfügbaren technisch weit ausdifferenzierten Schrittmachersysteme bei terminal schwerstkranken Patienten. Die Palliativmedizin sollte als komplementäre Versorgungsstruktur unbedingt in die Therapieplanung der chronisch kranken, schwer herzinsuffizienten Patienten integriert werden.

Schlüsselwörter

Herzinsuffizienz Ethik Schrittmacher Mechanische Kreislaufunterstützung Lebensende 

The chronic critically ill patient from the cardiologist’s perspective

Abstract

In recent years the prognosis and survival of chronic and acute heart failure (HF) patients has been steadily improving; however, many patients develop advanced chronic HF which is characterized by worsening of symptoms, unplanned hospital admission due to acute decompensation, development of complications, such as life-threatening arrhythmia and shorter life span. Optimal medical therapy is supplemented by interventional cardiology, cardiovascular implantable electronic devices (CIEDs), minimally invasive valve replacement or repair, circulatory mechanical support and heart transplantation. Medical indications and informed consent are essential prerequisites for successfully implementing treatment goals. For patients who are incapable of decisions a legally defined surrogate decision-maker has the same right to refuse or request the withdrawal of treatment as the patient would have if the patient had decision-making capability. As the use of circulatory mechanical support becomes increasingly more prevalent, ethical issues are likely to arise at an increasing rate, as will social and legal ramifications. The concept of turning off an implanted device as death nears is challenging because of ethical and technical concerns. The same holds true for CIEDs. A palliative care approach is applicable to heart failure patients and is particularly relevant to those with advanced disease. Palliative care should be integrated as part of a team approach to comprehensive HF care and should not be reserved for those who are expected to die within days or weeks.

Keywords

Heart failure Ethics Pacemaker Ventricular assist device End of life 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt für sich und seinen Koautor an, dass kein Interessenkonflikt besteht.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Klinik für Innere MedizinSt. Antonius HospitalEschweilerDeutschland
  2. 2.Klinik für Kardiologie, Pneumologie, Angiologie und Internistische IntensivmedizinUniversitätsklinikum AachenAachenDeutschland

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