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Der chronisch kritisch kranke Patient aus der Perspektive des Kardiologen

The chronic critically ill patient from the cardiologist’s perspective

  • Leitthema
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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.

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.

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Literatur

  1. (o A) (2004) National Consensus Project for Quality Palliative Care: Clinical practice guidelines for quality palliative care, executive summary. J Palliat Med 7:611–627

    Google Scholar 

  2. (o A) (2011) Grundsätze der Bundesärztekammer zur Sterbebegleitung. Dtsch Arztebl 108:A346–A348

    Google Scholar 

  3. Allen LA, Stevenson LW, Grady KL et al (2012) Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 125:1928–1952

    Article  PubMed  Google Scholar 

  4. Ammar KA, Jacobsen SJ, Mahoney DW et al (2007) Prevalence and prognostic significance of heart failure stages: application of the American College of Cardiology/American Heart Association heart failure staging criteria in the community. Circulation 115:1563–1570

    Article  PubMed  Google Scholar 

  5. Beauchamp TL, Childress JF (2009) Principles of biomedical ethics. Oxford University Press, New York

  6. Borasio GD, Heßler H-J, Wiesing U (2009) Patientenverfügungsgesetz – Umsetzung in der klinischen Praxis. Dtsch Arztebl 106:A1952–A1957

    Google Scholar 

  7. Carlsson J, Paul NW, Dann M et al (2012) Deaktivierung von implantierbaren Defibrillatoren. Medizinische, ethische, praktische und juristische Aspekte. Dtsch Arztebl Int 109:535–541

    PubMed  Google Scholar 

  8. Daubert JC, Saxon L, Adamson PB et al (2012) 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace 14:1236–1286

    Article  PubMed  Google Scholar 

  9. DeVita MA, Groeger J, Truog R (2003) Current controversies in critical care ethics: not just end of life. Crit Care Med 31:S343

    Article  PubMed  Google Scholar 

  10. Dickstein K, Vardas PE, Auricchio A et al (2010) 2010 focused update of ESC guidelines on device therapy in heart failure: an update of the 2008 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2007 ESC guidelines for cardiac and resynchronization therapy. Developed with the special contribution of the Heart Failure Association and the European Heart Rhythm Association. Eur J Heart Fail 12:1143–1153

    Article  PubMed  Google Scholar 

  11. England R, England T, Coggon J (2007) The ethical and legal implications of deactivating an implantable cardioverter-defibrillator in a patient with terminal cancer. J Med Ethics 33:538–540

    Article  PubMed  Google Scholar 

  12. Entwistle JW, Sade RM, Petrucci RJ (2011) The ethics of mechanical support: the need for new guidelines. Ann Thorac Surg 92:1939–1942

    Article  PubMed  Google Scholar 

  13. Fox CS, Evans JC, Larson MG et al (2004) Temporal trends in coronary heart disease mortality and sudden cardiac death from 1950 to 1999: the Framingham Heart Study. Circulation 110:522–527

    Article  PubMed  Google Scholar 

  14. Gahl K (2005) Indikation – zur Begründungsstruktur ärztlichen Handelns. Dtsch Med Wochenschr 130:1155–1158

    Article  PubMed  CAS  Google Scholar 

  15. Goldstein NE, May CW, Meier DE (2011) Comprehensive care for mechanical circulatory support: a new frontier for synergy with palliative care. Circ Heart Fail 4:519–527

    Article  PubMed  Google Scholar 

  16. Hamm CW, Bassand JP, Agewall S et al (2011) ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 32:2999–3054

    Article  PubMed  Google Scholar 

  17. Hunt SA, Abraham WT, Chin MH et al (2009) 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119:e391–e479

    Article  PubMed  Google Scholar 

  18. Jaarsma T, Beattie JM, Ryder M et al (2009) Palliative care in heart failure: a position statement from the palliative care workshop of the heart failure association of the European society of cardiology. Eur J Heart Fail 11:433–443

    Article  PubMed  Google Scholar 

  19. Janssens U (2010) Ethik. In: Welte T (Hrsg) Handbuch IntensivUpdate 2010. Med Publico 2010, Wiesbaden, S 16\1–16\44

  20. Janssens U (2012) Die akute Herzinsuffizienz. Med Klin Intensivmed Notfmed 107:397–423

    PubMed  CAS  Google Scholar 

  21. Janssens U, Burchardi N, Duttge G et al (2012) Therapiezieländerung und Therapiebegrenzung in der Intensivmedizin. DIVI 3:103–107

    Google Scholar 

  22. Janssens U, Karg O (2012) Sterben am/trotz Beatmungsgerät. DIVI 3:145–155

    Google Scholar 

  23. Kamouh A, Francis GS (2011) Contemporary management and research directions in advanced heart failure: where are we going? Congest Heart Fail 17:241–247

    Article  PubMed  Google Scholar 

  24. Kato TS, Schulze PC, Yang J et al (2012) Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant 31:1–8

    Article  PubMed  Google Scholar 

  25. Kay GN, Bittner GT (2009) Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated? Deactivating implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness. An ethical distinction. Circ Arrhythm Electrophysiol 2:336–339

    Article  PubMed  Google Scholar 

  26. Khazanie P, Rogers JG (2011) Patient selection for left ventricular assist devices. Congest Heart Fail 17:227–234

    Article  PubMed  Google Scholar 

  27. Kirklin JK, Naftel DC, Kormos RL et al (2012) The fourth INTERMACS annual report: 4,000 implants and counting. J Heart Lung Transplant 31:117–126

    Article  PubMed  Google Scholar 

  28. Kirklin JK, Naftel DC, Kormos RL et al (2010) Second INTERMACS annual report: more than 1,000 primary left ventricular assist device implants. J Heart Lung Transplant 29:1–10

    Article  PubMed  Google Scholar 

  29. Kramer DB, Mitchell SL, Brock DW (2012) Deactivation of pacemakers and implantable cardioverter-defibrillators. Prog Cardiovasc Dis 55:290–299

    Article  PubMed  Google Scholar 

  30. Lampert R, Hayes DL, Annas GJ et al (2010) HRS expert consensus statement on the management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 7:1008–1026

    Article  PubMed  Google Scholar 

  31. Lanken PN, Terry PB, Delisser HM et al (2008) An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 177:912–927

    Article  PubMed  Google Scholar 

  32. May AT (2012) Der Wille des Patienten in der Intensivmedizin. In: Salomon F (Hrsg) Praxisbuch Ethik in der Intensivmedizin. MWV, Berlin, S 111–121

  33. McKelvie RS, Moe GW, Cheung A et al (2011) The 2011 canadian cardiovascular society heart failure management guidelines update: focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care. Can J Cardiol 27:319–338

    Article  PubMed  Google Scholar 

  34. McMurray JJ, Adamopoulos S, Anker SD et al (2012) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 33:1787–1847

    Article  PubMed  Google Scholar 

  35. McMurray JJ, Adamopoulos S, Anker SD et al (2012) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 14:803–869

    Article  PubMed  CAS  Google Scholar 

  36. Metra M, Ponikowski P, Dickstein K et al (2007) Advanced chronic heart failure: a position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 9:684–694

    Article  PubMed  Google Scholar 

  37. Miller LW, Pagani FD, Russell SD et al (2007) Use of a continuous-flow device in patients awaiting heart transplantation. N Engl J Med 357:885–896

    Article  PubMed  CAS  Google Scholar 

  38. Mohacsi P, Stalder M, Marinelli M et al (2011) Herztransplantation und mechanische Kreislaufunterstützung. Aktueller Stand und Perspektiven (Teil 2). Schweiz Med For 11:98–102

    Google Scholar 

  39. Murray SA, Kendall M, Boyd K et al (2005) Illness trajectories and palliative care. BMJ 330:1007–1011

    Article  PubMed  Google Scholar 

  40. Nauck F (2011) Ethische Aspekte in der Therapie am Lebensende. Med Klin Intensivmed Notfmed 106:137–148

    Article  PubMed  CAS  Google Scholar 

  41. Neumann T, Biermann J, Erbel R et al (2009) Herzinsuffizienz: Häufigster Grund für Krankhenhausaufenthalte. Medizinische und ökonomische Aspekte. Dtsch Arztebl Int 106:269–275

    PubMed  Google Scholar 

  42. Norton C, Georgiopoulou VV, Kalogeropoulos AP et al (2011) Epidemiology and cost of advanced heart failure. Prog Cardiovasc Dis 54:78–85

    Article  PubMed  Google Scholar 

  43. Padeletti L, Arnar DO, Boncinelli L et al (2010) EHRA expert consensus statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy. Europace 12:1480–1489

    Article  PubMed  Google Scholar 

  44. Petrucci RJ, Benish LA, Carrow BL et al (2011) Ethical considerations for ventricular assist device support: a 10-point model. ASAIO J 57:268–273

    Article  PubMed  Google Scholar 

  45. Rizzieri AG, Verheijde JL, Rady MY et al (2008) Ethical challenges with the left ventricular assist device as a destination therapy. Philos Ethics Humanit Med 3:20

    Article  PubMed  Google Scholar 

  46. Roger VL, Go AS, Lloyd-Jones DM et al (2012) Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation 125:e2–e220

    Article  PubMed  Google Scholar 

  47. Simon A (2010) Patientenverfügung in der Intensiv- und Notfallmedizin. Intensivmed 47:43–48

    Article  Google Scholar 

  48. Slaughter MS, Rogers JG, Milano CA et al (2009) Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 361:2241–2251

    Article  PubMed  CAS  Google Scholar 

  49. Steg PG, James SK, Atar D et al (2012) ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 33:2569–2619

    Article  PubMed  CAS  Google Scholar 

  50. Sulmasy DP (2008) Within you/without you: biotechnology, ontology, and ethics. J Gen Intern Med 23(Suppl 1):69–72

    Article  PubMed  Google Scholar 

  51. Thompson KA, Philip KJ, Barbagelata A et al (2010) Review article: the new concept of interventional heart failure therapy – part 1: electrical therapy, treatment of CAD, fluid removal, and ventricular support. J Cardiovasc Pharmacol Ther 15:102–111

    Article  PubMed  Google Scholar 

  52. Vahanian A, Alfieri O, Andreotti F et al (2012) Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 33:2451–2496

    Article  PubMed  Google Scholar 

  53. Verrel T (2012) Die Rolle des Rechts bei Behandlungsentscheidungen am Lebensende. In: Salomon F (Hrsg) Praxisbuch Ethik in der Intensivmedizin. MWV, Berlin, S95–S110

  54. Werdan K, Ruß M, Buerke M et al (2011) Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. Intensivmed 48:291–344

    Article  Google Scholar 

  55. Word Health Organization Definition of palliative care(2010) http://www.who.int/cancer/palliative/definition/en

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  1. Klinik für Innere Medizin, St. Antonius Hospital, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland

    U. Janssens

  2. Klinik für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Aachen, Aachen, Deutschland

    S. Reith

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Janssens, U., Reith, S. Der chronisch kritisch kranke Patient aus der Perspektive des Kardiologen. Med Klin Intensivmed Notfmed 108, 267–278 (2013). https://doi.org/10.1007/s00063-012-0193-z

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  • DOI: https://doi.org/10.1007/s00063-012-0193-z

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