Abstract
Dear Editor:
Because of recent progress in implantable cardioverter-defibrillator (ICD) technology, the number of patients with cancer who undergo placement of ICDs is increasing. Novel guidelines 1 for patients with heart failure recommend discussion of ICD deactivation as a part of advance care planning (ACP). However, no guidelines have addressed ICD deactivation for patients with cancer. In previous reports,2,3 31% of patients with ICDs experienced shocks in the past 24 hours before death due to tachycardia triggered by hypoxia and electrolyte imbalances and patients who experienced frequent shocks suffered from more severe pain. We herein report a case involving a patient with advanced cancer who developed refractory chest pain induced by ICD shocks in his end-of-life stage. The chest pain disappeared by ICD deactivation through appropriate ACP in cooperation with multiple experts.
A 70-year-old man with idiopathic dilated cardiomyopathy and chronic heart failure was diagnosed with carcinoma of unknown primary in July 2017. Because his life expectancy was longer than several months, an ICD was implanted for symptomatic ventricular tachycardia in November 2017. When he was referred to our outpatient clinic in July 2018 after termination of anticancer treatments, we discussed the timing of ICD deactivation among multiple experts (oncologists, cardiologists, and palliative care specialists). At that time, we decided that the ICD should be deactivated immediately before death because his prognosis seemed to be determined by both cancer progression and lethal arrhythmia. In fact, his ICD records showed several ICD shocks during the past few months before the discussion. The patient and his wife agreed with our suggestion. On admission to our palliative care unit in August 2018, he complained frequent severe chest pain that was refractory to analgesics such as opioids. The ICD records showed 14 times ICD shocks against ventricular fibrillation or ventricular tachycardia during the past 2 days. We consulted with the cardiologists again and concluded that ICD deactivation was appropriate in terms of the risk–benefit balance considering his short life expectancy (around 1 week) and his pain-free status after the deactivation despite a risk of sudden death by lethal arrhythmia. The patient and his wife agreed with our suggestion. After the deactivation, the chest pain disappeared and he died 8 days after admission with no painful episodes, although we could not confirm evidence of lethal arrhythmia by electrocardiography.
To the best of our knowledge, this is the first report of severe pain induced by ICD shocks and disappearance of the pain by ICD deactivation in a patient with cancer. We believe that owing to the first discussion about ICD deactivation among multiple experts just after an anticancer treatment termination, the second discussion to remove his pain was carried out quite rapidly. Since ACP has become a global standard for patients at end-of-life stage, the timing of ICD deactivation should be repeatedly discussed as a part of ACP in patients with ICDs in cooperation with multiple experts.
