Special article
Guidelines on the management of implantable cardioverter defibrillators at the end of life
Guía sobre el manejo de desfibriladores automáticos implantables al final de la vida
T. Datinoa, L. Rexachb, M.T. Vidánc, A. Alonsod, Á. Gándarae, J. Ruiz-Garcíaf, B. Fontechag, M. Martínez-Sellésa,h,i,
Corresponding author
a Unidad de Arritmias y Electrofisiología, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Unidad de Cuidados Paliativos, Hospital Universitario Ramón y Cajal, Madrid, Spain
c Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain
d Unidad de Cuidados Paliativos, Hospital Universitario La Paz, Madrid, Spain
e Unidad del Dolor y Cuidados Paliativos, Clínica Ruber, Madrid, Spain
f Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
g Servicio de Geriatría y Cuidados Paliativos, Consorci Sanitari Integral L’Hospitalet de Llobregat, Barcelona, Spain
h Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
i Universidad Europea de Madrid, Madrid, Spain
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"apellidos" => "Martínez-Sellés" "email" => array:1 [ 0 => "mmselles@secardiologia.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Unidad de Arritmias y Electrofisiología, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Paliativos, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Cuidados Paliativos, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad del Dolor y Cuidados Paliativos, Clínica Ruber, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Geriatría y Cuidados Paliativos, Consorci Sanitari Integral L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Universidad Europea de Madrid, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guía sobre el manejo de desfibriladores automáticos implantables al final de la vida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2228 "Ancho" => 3000 "Tamanyo" => 432302 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm with the steps to take when the patient requests the disconnection of the implantable cardioverter defibrillator (ICD) until the deactivation has been performed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background. Ethical and legal principles</span><p id="par0005" class="elsevierStylePara elsevierViewall">Implantable cardioverter defibrillators (ICDs) are devices that are indicated in patients with severe heart disease who have experienced sudden death by ventricular tachyarrhythmia or who are at high risk of experiencing it. The use of ICDs has increased, and more than 5000 ICDs are implanted every year in Spain, with a rate of 116 implants per million inhabitants, a figure well below the European average of 269 implants per million inhabitants.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is increasingly frequent to find patients carrying ICDs in the final stages of disease, which has led a number of authors to recommend a screening routine in palliative care programs to detect ICD carriers and proceed accordingly.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In these patients, the permanence of these active devices can prolong unnecessary suffering, given that the patients frequently receive discharges from them, which are painful and decrease the quality of life.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Furthermore, these patients are often treated by professionals who are not sufficiently prepared to address these conditions. The present document is aimed primarily at doctors but is also directed to nurses and healthcare professionals who interact with patients who carry these devices. Given that a large majority of these patients are over 65 years of age,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> this document is focused on elderly patients; however, the decision-making process is similar in younger ICD carriers in end-stage situations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Previous studies have shown that patients receive little information related to the decision-making process and management of ICDs in the final stages of life. Specifically, few patients with ICDs receive information from their reference professionals on the benefits and dangers of these devices in the advanced stages of disease and, as a result, their deactivation is considered in only a few of these patients.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6,7</span></a> The communication of sufficient information is not only a patient's right and an ethical obligation for the physician but it also allows for patient participation in the complex clinical decisions that are undertaken at the end of life. It also facilitates the adaptation and the perception of control by reducing uncertainty and allows for the possibility of planning with real objectives. It is not just a matter of reporting the diagnosis and prognosis of a specific disease but rather the discovery of patients’ values and preferences, including patients in the decision-making process and making them active in the final process of life.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> From an ethical standpoint, the limitation of the therapeutic effort consists in not applying extraordinary and/or disproportionate measures for the established therapeutic goal in a patient with a poor vital prognosis and/or poor quality of life. In this context and given that ICD deactivation does not imply the immediate death of the patient, deactivation should be considered as a form of limiting the therapeutic effort. Advance directives encourage patient participation in decision making in situations where they cannot express their wishes themselves. A recent study showed that patients who had prepared advance directives received care associated with their preferences.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The directives also represent an opportunity for dialog with patients, facilitating clinical decisions, promoting a feeling of control by the patient and improving the clinical care relationship.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In an effort to cover the gap in Spain in the management of ICDs in the final stages of life, the Spanish Society of Geriatric Medicine and Gerontology, the Spanish Society of Palliative Care and the Geriatric Cardiology Section of the Spanish Society of Cardiology have developed the present document. The objectives of this document are as follows: (1) To describe the ethical, legal and clinical issues related to the deactivation of ICDs in patients in terminal conditions. (2) To highlight the importance of communication and a multidisciplinary approach. (3) To provide decision-making schemes to guide clinicians in caring for these types of patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0020" class="elsevierStylePara elsevierViewall">The present consensus was developed in the meeting “Palliative Care in Cardiology”, held in Madrid in November 2012. The meeting was not sponsored, registration was free and open to all professionals and had 120 attendees. Upon confirming the difficulty of managing these patients, a multidisciplinary workgroup was created to develop this document.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient evaluation integrated geriatric assessment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Geriatric assessment is a broad term used to describe the health evaluation of elderly patients, with an emphasis on components and results that differ from those of a standard medical assessment. This approach assumes that the health status of elderly patients depends on various influences beyond the manifestations of the disease itself. These influences include the social sphere, psychological and mental health and environmental factors. Principles similar to these can be used for patients in the final phases of life, regardless of age. The usefulness of the integrated geriatric assessment in the decision-making process is two-fold. On one hand, it informs us of the prognosis of patients in terms of the disease and patient functionality. On the other, it informs us of the degree of competence for making such complex decisions. One of the key issues in geriatric assessment is the evaluation of the functional condition, given that it is one of the main factors that determine the prognosis.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–13</span></a> A number of scales, such as the Katz Index of Independence, can be useful when performing this assessment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The components of the geriatric assessment also include the traditional assessment of disease symptoms and their treatments, a cognitive, affective, functional, socio-economic and spiritual assessment, especially in regard to advance directives. This geriatric assessment should be performed before ICD placement when treating geriatric patients and/or in each of the episodes of obvious worsening of the disease, especially if the patient requires hospitalization.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conversations with the patient: objectives</span><p id="par0030" class="elsevierStylePara elsevierViewall">To achieve an open discussion in which the patient, after understanding the disease and its outcome, takes an active role in directing the therapy objectives, improving the final quality-of-life and patient satisfaction results.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However, few ICD carriers discuss the issues related to device deactivation with their physicians or are aware that such deactivation is a correct and ethically valid option.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,16</span></a> A study performed in hospices in the USA showed that the majority of ICD carriers with terminal diseases had not be counseled on its deactivation. Many of these carriers had received repeated shocks at the end of their life,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and although a number of studies suggest a certain improvement in the degree of information received by these patients,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> there is still much to be done. The following are a number of key issues that need to be treated in patient discussions:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(1)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients should understand that although treatment with an ICD is a therapeutic option whose fundamental objective is to prevent sudden death of arrhythmic origin, as heart disease progresses or when the final phase life is reached by another coexisting disease, the prognosis can be determined by issues other than the risk of sudden death. Patients should also be aware that, in the preagony phases, the device can emit numerous electrical shocks in an attempt to prevent cardiac arrest, with the resulting suffering and detriment to the patient's quality of life, at a time when well-being and peace are more important than a few more hours of life. Thus the preventive objective for placing the ICD can cease to be of importance at a certain point in time and instead could even become a source of discomfort.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(2)</span><p id="par0040" class="elsevierStylePara elsevierViewall">When the survival time is determined by the disease itself, deactivation of the electrical shock function is legal and ethically correct; it will not result in a reduced life expectancy and is not a form of euthanasia.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(3)</span><p id="par0045" class="elsevierStylePara elsevierViewall">It should also be clear from the start that the decision of a possible deactivation of the device, which should be discussed thoroughly with the medical team, is ultimately the decision of the patient or the person in whom the patient delegates the care, in the event that the decision-making ability is lost. This decision can also change over time depending on the circumstances and the essential therapeutic objectives as the disease progresses. The patient can decide to undergo a deactivation that was initially rejected or reactivate a previously deactivated function.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(4)</span><p id="par0050" class="elsevierStylePara elsevierViewall">It is important to properly explain that there are numerous treatment options that depend on the device and that it is possible to deactivate only a few of them. It is also important to explain that deactivating the electric shock function does not mean death immediately afterwards.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(5)</span><p id="par0055" class="elsevierStylePara elsevierViewall">In addition to deactivation, there is another possible option for discontinuing treatment: not replacing the device when its battery has run out. It should be taken into account that this change involves an invasive technique with the risk of complications.</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">The decision to deactivate the device can be very difficult for patients, and they should always have enough time to think it through, consult and discuss all related questions and to calmly make the decision at a later time. The results of this decision should always be reflected in the patient's medical history.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Patient decision-making competence</span><p id="par0065" class="elsevierStylePara elsevierViewall">Doctors should document whether, in their opinion, the patient is capable of understanding the discussion and whether they have sufficient emotional stability to be competent in the decision to disconnect the ICD. Underlying depression can distort judgment and can result in an inappropriate request to disconnect all functions of the ICD. In these cases, a specific psychiatric evaluation and psychological support measures should be considered before making decisions. Religious support should also be offered in cases where the patient considers it necessary for making a decision due to their deep convictions and beliefs. The degree of competence required for the decisions varies<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>; that required to understand and reach a decision to deactivate a device such as the ICD would be similar to that of participating in a clinical trial. Occasionally, competence evaluation can be a complex process. There are standardized tools available for such a process (the MacArthur Competence Assessment Tool, the Sitges document),<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a> especially designed for patients with cognitive disorders. We consider that the importance of the decision merits leaving documented evidence of the information procedure performed and the patient consent (or that of their representative) procedure. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> can be of use in guiding the steps of the conversation.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Communication and multidisciplinary approach</span><p id="par0070" class="elsevierStylePara elsevierViewall">The discussion with the patient about possible conditions in which ICD deactivation can be contemplated should be conducted prior to the implantation of the device (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>),<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a> and the options of ICD deactivation should be included in the informed consent prior to implantation. In each device control visit, any changes in the patient's health, new diagnoses and worsening of previously known diseases should be considered. When the patient's deterioration in health becomes very significant, a change in the therapeutic approach can be decided, focusing the objectives of the therapy on the patient's well-being and even electing the option of no resuscitation.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In this stage of the disease, it is essential to discuss the deactivation of the ICD. At the same time, the communication must be very fluid among the various specialists, from the clinician in charge of the patient (family doctor to home support teams, internist, geriatrician and cardiologist) up to the electrophysiologist, to avoid giving conflicting information and so that the entire care team shares opinions and criteria as if from a single contact. It does not seem appropriate that the electrophysiologist should be the only doctor responsible for the deactivation decision; therefore, it is crucial to identify the reference professional for the patient. Although the technical implementation of the modifications to the characteristics of the ICD is commonly performed in the arrhythmia unit, it should always be preceded by a diagnostic procedure of the end-stage condition and the suitability of de/reprogramming the device.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Multilevel process: the role of the family</span><p id="par0075" class="elsevierStylePara elsevierViewall">The decision shared with loved ones is very important. On many occasions in the advanced phases of the disease, the patients, especially the elderly, tend to lose their desire to control the condition and trust more in their loved ones, delegating to them the complex decisions. The family adopts an even more relevant role in situations where the patient is cognitively incapacitated and there are no prior instructions. The family should be instructed so that they can make decisions while attempting to base these decisions on what they consider to be the patient's prior will and not following their own wishes. When there is no representative chosen by the patient or legally appointed and there is no agreement among the family members, the Ethics Committee should be consulted. A potentially problematic situation can arise when there is disagreement between the will that an incapacitated patient stated a long time before their current disease and a different approach perceived by the family to act in the patient's current situation. The wishes of the patient always have priority over those of the family.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Logistics of the deactivation</span><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> describes in the form of an algorithm the complete logistics of the deactivation process. Throughout the process, it should be understood that the information concerning the implant center and the model and manufacturer of the device appear on the card that all ICD carriers have with them at all times. One of the first steps to follow before ordering the deactivation of the ICD is to determine whether the patient is truly in the position to make this decision freely and knowledgeably. In certain cases, the doctor who wants to order the deactivation may deem it necessary to first consult or request the participation of an electrophysiologist or cardiologist. This might be required if the doctor's level of understanding of the operation of the ICD is insufficient, thus limiting the information the doctor can provide. It is recommendable in cases where the doctor believes that, after the deactivation of certain therapies, significant clinical deterioration might occur that requires adjusting the cardiac medication (for example, when treating a patient with ventricular tachycardia and/or bradycardia that can worsen the functional class, palpitations or syncope).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The doctor who most closely follows the patient should be the one responsible for giving the order to deactivate the ICD, always in accordance with the patient's wishes, and this decision should be recorded in writing before the deactivation. Only in emergency situations can this order be verbal, although in these cases the decision should always be detailed in the patient's medical history within 24<span class="elsevierStyleHsp" style=""></span>h. According to the recommendations of the main European and American scientific societies,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a> the content of the ICD deactivation order should always confirm that:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(1)</span><p id="par0090" class="elsevierStylePara elsevierViewall">it is the patient (or their representative) who has requested the deactivation,</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">(2)</span><p id="par0095" class="elsevierStylePara elsevierViewall">the patient (or their representative) has the capacity to make this type of decision,</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">(3)</span><p id="par0100" class="elsevierStylePara elsevierViewall">the available therapeutic alternatives have been discussed,</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">(4)</span><p id="par0105" class="elsevierStylePara elsevierViewall">the consequences of the deactivation have been clarified,</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">(5)</span><p id="par0110" class="elsevierStylePara elsevierViewall">the ICD therapies that will be deactivated have been clearly specified, and</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">(6)</span><p id="par0115" class="elsevierStylePara elsevierViewall">the family has been informed that the deactivation will take place, inasmuch as the patient has so requested and/or accepted.</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">It is recommended that the deactivation of the device be performed by a cardiologist with experience in programming ICDs or by technicians from companies specialized in these devices, always under the direction of medical personnel. Whenever possible, the therapies should be deactivated in the presence of a family member. If the medical personnel or technician responsible for performing the deactivation prefers not to perform the procedure, another qualified individual who has no such objection should be designated. In terms of the reprogramming itself, consideration has to be given the following (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>):<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">(a)</span><p id="par0125" class="elsevierStylePara elsevierViewall">Generally, it is desirable to avoid the pain produced by the discharges during cardioconversion of the tachycardia. This is achieved by deprogramming the detection and/or all therapies. However, ICDs usually have other types of programmed therapies to remove tachycardia that are not painful. These therapies stimulate the ventricle faster than the tachycardia in an attempt to remove the tachycardia (known as “antitachycardia pacing” or more commonly by its initials ATP). If the ventricular tachycardia is rapid and has the potential to cause sudden death, deactivating the ATP might have the objective of avoiding extending the patient's life. In contrast, slow ventricular tachycardia does not usually cause death directly and instead worsens the symptoms of heart failure. In these cases, deactivating the electric discharges and leaving the ATP is recommended.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">(b)</span><p id="par0130" class="elsevierStylePara elsevierViewall">There is usually no reason to deactivate the pacemaker function because these patients are generally not dependent on the pacemaker function. For patients with bradycardia, the pacemaker stimulation is not painful and avoids the symptoms secondary to bradycardia (dizziness, presyncope, dyspnea, etc.), which are definitely not desirable and only worsen the patient's quality of life.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">(c)</span><p id="par0135" class="elsevierStylePara elsevierViewall">ICDs with resynchronization functionality: This therapy is not painful and can reduce the symptoms of the heart failure. Therefore, in general, the cardiac resynchronization activity should be maintained.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">(d)</span><p id="par0140" class="elsevierStylePara elsevierViewall">In emergency situations in which the patient receives painful and repetitive therapies (which is generally known as an electrical storm) if the deactivation cannot be accomplished quickly with the programmer, a magnet can be applied to the ICD generator, which would temporarily suspend all antitachycardia therapies while maintaining the antibradycardia function. There are rounded magnets designed specifically for this purpose (commonly referred to as “donuts”). It is highly recommended than these magnets be available in centers that treat patients who carry ICDs. In desperate situations, household magnets can be used given that they have been reported to deactivate ICDs.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li></ul></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Peculiarities of deactivation according to the location of the patient</span><p id="par0145" class="elsevierStylePara elsevierViewall">If the patient is hospitalized, 2 situations can arise:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">(a)</span><p id="par0150" class="elsevierStylePara elsevierViewall">Hospitals with sufficient means and staff for the management of ICDs: The responsible physician records the order for deactivation, and contacts the section in charge of programming and monitoring intracardiac devices. This section will reprogram the ICD according to the request, recording the manner in which the ICD is reprogrammed (whether all therapies are switched off or whether antibradycardia and/or antitachycardia therapy is maintained).</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">(b)</span><p id="par0155" class="elsevierStylePara elsevierViewall">Hospital without sufficient means or staff for the deactivation: The responsible physician should contact the center that is performing the periodic reviews. A timely transfer to this center can be planned for the deactivation as long as this does not cause the patient significant problems. If a transfer is not appropriate, the center that performed the implantation of the ICD or its monitoring can send the necessary staff and materials to conduct the deactivation. If there is no possibility of contacting a nearby center with staff trained in the handling of ICDs, the manufacturer should be contacted so that they can provide the programmer and necessary instructions to conduct the deactivation. Given the emotional burden caused by ICD deactivation,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,16</span></a> it is recommended that this deactivation be performed in the presence of the responsible doctor.</p></li></ul></p><p id="par0160" class="elsevierStylePara elsevierViewall">In the case of outpatients, 2 situations can arise:</p><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">(a)</span><p id="par0170" class="elsevierStylePara elsevierViewall">Patients who visit the center where their ICD reviews are usually performed. In these cases, the patient's personal request, which meets with the previously described requirements, should be sufficient for performing the deactivation. The active approach of staff who perform these revisions, informing the patient about the possibility of ICD disconnection should a terminal illness be detected, significantly reduces the number of discharges suffered by the patient in the last days of life.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">(b)</span><p id="par0175" class="elsevierStylePara elsevierViewall">Patient who cannot visit a center for deactivation. The responsible doctor should contact the center where the implant and/or the regular reviews were conducted to see if they can supply the necessary materials and personnel. As a last resort, the manufacturer can be contacted in order to provide these resources. In this outpatient setting, the presence of the responsible doctor is even more important and recommended while the deactivation is conducted.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,16</span></a> We believe that deactivation by remote control is not recommended in any of the scenarios described; in fact, it is rejected by the majority of surveyed European doctors from various specialities.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></li></ul></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Fundamental issues of deactivation</span><p id="par0180" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">A.</span><p id="par0185" class="elsevierStylePara elsevierViewall">Once patients have given their consent to deactivating the ICD, it should only be performed once the responsible physician has given the order in writing, except in cases of emergency.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">B.</span><p id="par0190" class="elsevierStylePara elsevierViewall">Deactivation should be conducted within a set of other palliative care options.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">C.</span><p id="par0195" class="elsevierStylePara elsevierViewall">The doctor responsible, under the supervision of an expert cardiologist in ICD, should indicate the specific therapies to reprogram. The central point is usually the deactivation of painful defibrillation therapies (in emergency situations, this can be performed on a temporary basis by applying a magnet to the generator).</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "xres307802" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec290881" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres307801" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec290882" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background. Ethical and legal principles" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient evaluation integrated geriatric assessment" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conversations with the patient: objectives" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Patient decision-making competence" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Communication and multidisciplinary approach" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Multilevel process: the role of the family" ] 11 => array:3 [ "identificador" => "sec0040" "titulo" => "Logistics of the deactivation" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Peculiarities of deactivation according to the location of the patient" ] ] ] 12 => array:2 [ "identificador" => "sec0050" "titulo" => "Fundamental issues of deactivation" ] 13 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-21" "fechaAceptado" => "2013-08-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec290881" "palabras" => array:4 [ 0 => "Implantable cardioverter defibrillator" 1 => "Palliative care" 2 => "Decision-making" 3 => "Treatment retrieval" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec290882" "palabras" => array:4 [ 0 => "Desfibrilador automático implantable" 1 => "Cuidados paliativos" 2 => "Toma de decisiones" 3 => "Retirada de tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This article is a joint document of the Spanish Society of Geriatrics and Gerontology, the Spanish Society of Palliative Care and the Section of Geriatric Cardiology of the Spanish Society of Cardiology. Its aim is to address the huge gap that exists in Spain with regard to the management of implantable cardioverter defibrillators (ICDs) in the final stages of life. It is increasingly common to find patients carrying these devices that are in the terminal stage of an advanced disease. This occurs in patients with advanced heart disease and subsequent heart failure refractory to treatment but also in a patient with an ICD who develops cancer disease, organ failure or other neurodegenerative diseases with poor short-term prognosis. The vast majority of these patients are over 65, so the paper focuses particularly on the elderly who are in this situation, but the decision-making process is similar in younger patients with ICDs who are in the final phase of their life.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El presente artículo es un documento conjunto de la Sociedad Española de Geriatría y Gerontología, la Sociedad Española de Cuidados Paliativos y la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología. Su objetivo es paliar la laguna que existe en España en lo que respecta al manejo de los desfibriladores automáticos implantables (DAI) en las fases finales de la vida. Cada vez es más frecuente encontrarse enfermos portadores de DAI en fase terminal de una enfermedad avanzada, como insuficiencia cardíaca refractaria, enfermedades oncológicas, otras insuficiencias orgánicas o enfermedades neurodegenerativas con mal pronóstico a corto plazo. La enorme mayoría de estos pacientes tiene más de 65 años, por ello el documento se enfoca de forma particular a los ancianos que se encuentran en esta situación, aunque el proceso de toma de decisiones es similar en portadores de DAI más jóvenes que están en la fase final de su vida.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Datino T, Rexach L, Vidán MT, Alonso A, Gándara Á, Ruiz-García J, et al. Guía sobre el manejo de desfibriladores automáticos implantables al final de la vida. Rev Clin Esp. 2014;214:31–37.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2228 "Ancho" => 3000 "Tamanyo" => 432302 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm with the steps to take when the patient requests the disconnection of the implantable cardioverter defibrillator (ICD) until the deactivation has been performed.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Identify the terminal condition. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Identify its etiology (cardiac or other). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Balance the risks and benefits of not deactivating. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assess the patient's capacity and competence to decide. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommend the therapeutic option that is most coherent with the patient's overall objective. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respect any decision made by the patient. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Record the decision taken in the medical history and reports. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab455041.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Required steps in the conversations prior to making decisions about the deactivation of an implantable cardioverter defibrillator (ICD).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: ICD, implantable cardioverter defibrillator.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior to the implementation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The patient should understand the benefits and disadvantages that the device provides and all key issues in regards to deactivation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any time there is worsening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reassess the benefits and drawbacks of the ICD and assess functionality, quality of life and symptoms. Talk about the fundamental objective of therapy in this new phase. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After repeated discharges \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discuss alternatives or whether device adjustments can improve the quality of life. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When shaping the order “do not resuscitate” \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reassess the benefits of the ICD and the logic of keeping all of its functions active. Provide psychological support. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the final phase of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reassess the positive and negative aspects of the ICD and whether it is worth keeping it active. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab455040.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Times when discussing the deactivation of an implantable cardioverter defibrillator is necessary.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Present in all implantable cardioverter defibrillator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Causes pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Deactivate in terminal phase \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Defibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stop tachycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antitachycardia pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stop tachycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">According to the tachycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pacemakers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stimulate if there is bradycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resynchronization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improve ventricular synchrony \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab455042.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Programmable therapies of the implantable cardioverter defibrillator and general recommendations about its reprogramming in terminal patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Registro Español de Desfibrilador Automático 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 2 | 3 | 5 |
| 2018 February | 4 | 0 | 4 |
| 2018 January | 10 | 0 | 10 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 18 | 0 | 18 |
| 2017 October | 11 | 0 | 11 |
| 2017 September | 8 | 0 | 8 |
| 2017 August | 5 | 0 | 5 |
| 2017 July | 12 | 0 | 12 |
| 2017 June | 19 | 0 | 19 |
| 2017 May | 8 | 0 | 8 |
| 2017 April | 7 | 0 | 7 |
| 2017 March | 22 | 0 | 22 |
| 2017 February | 12 | 0 | 12 |
| 2017 January | 16 | 0 | 16 |
| 2016 December | 15 | 0 | 15 |
| 2016 November | 19 | 0 | 19 |
| 2016 October | 32 | 0 | 32 |
| 2016 September | 39 | 0 | 39 |
| 2016 August | 11 | 0 | 11 |
| 2016 July | 11 | 0 | 11 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
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