From January 2015 to January 2017, we encountered five terminal cancer patients with implantable cardioverter defibrillators (ICDs) in the palliative care unit of our hospital. Due to delirium or dementia, four of these five patients did not have the decision-making capacity to stop their ICD. Although one patient was capable of making his own decisions, his family did not agree with the medical professional considering the patient’s decision. The families of all five patients made decisions on behalf of the patients. The procedure for stopping the ICD was first discussed with the families at 2–21 days prior to the patients’ deaths. The ICDs were stopped between 3 h and 11 days prior to the patients’ deaths, following the consent of the families, which was obtained after 1–5 consultations. Through these experiences, we became aware of the following problems with regard to stopping ICDs: (1) the lack of experience of medical professionals in decision-making, (2) the lack of recognition of medical professionals to the distress caused to patients by ICDs, (3) the psychological burden and time constraint of discussions, and (4) the lack of knowledge of ICDs among patients and their families. These problems need to be addresses as part of advance care planning for cancer patients.
"},{"@language":"ja","@value":"当院緩和ケア病棟では，2015年1月から2017年1月の間に5例の植え込み型除細動器（implantable cardioverter-defibrillator: ICD）を有するがん終末期の患者を経験した．ICD停止について，5例中4例でせん妄や認知症により患者本人の意思決定能力がなく，1例は意思決定能力はあったが，家族が患者本人の意思確認に同意せず，5例とも家族による代理意思決定であった．ICD停止の手順は，家族と死亡の2〜21日前に話し合いを開始し，1〜5回の面談を経て同意を得たうえで，死亡の3時間〜11日前に停止した．今回の経験を通じて，ICD停止に関して①意思決定に関する医療者の経験不足，②ICDが患者に与える苦痛に関する医療者の認識不足，③話し合いにかかる心理的負担や時間的制約，④患者と家族のICDに関する知識不足，という問題点が明らかになった．がん患者のadvance care planningの一環としてこの問題に対応していく必要がある．
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