Other studies suggest that the mortality rate of chronic kidney disease and ESKD patients remains high[3-5] despite an AICD and complication rates of this device are higher compared with the non-ESKD population. Therefore, the use of an AICD as a life-prolonging intervention in ESKD

patients is controversial because the absence of clear survival benefit. In the trajectory of ESKD, a decision may be made that the continuation of an AICD is not in the patient’s best wishes or contrary to their stated goals of care. Those times may include the point where death is imminent or likely, where a decision is made to withdraw from dialysis for whatever reason, where the device is no longer considered effective, where multiple shocks occur related to disease progression, significantly worsening cardiac disease or cognitive impairment and patient preference. Usually, the object of care has shifted to a principal focus on the comfort p38 MAP Kinase pathway of the patient, rather than attempting to prevent death see more from arrhythmia. In that circumstance, it may be medically appropriate to deprogramme an AICD. Ideally, a discussion with the treating Cardiologist about the possible circumstances of deprogramming should occur at the time of implantation. As part of gaining the informed consent of the patient a full and clear explanation should be given of the

limitations of AICD therapy and the potential for deprogramming. In addition to the situations of crisis or change in focus of management described above, these discussions should also occur at the time of advance care planning and discussions surrounding cardiopulmonary resuscitation (CPR) orders. Those discussions may be conducted by many clinicians, including Nephrologists. The legal and ethical issues raised by deactivation

are identical to those raised by the withholding or withdrawing of all medical interventions. Critically, it is important to note that deprogramming AICDs does not constitute euthanasia or physician-assisted suicide, that Nabilone deprogramming AICD will not cause death and that the process of deprogramming is not painful or make the process of death more painful. The process of deprogramming should involve collaboration among the relevant health professionals, including the treating Nephrologist. Ideally, all centres and physicians who implant AICDs should have a formal pathway to undertake deprogramming. In summary, decisions regarding interventions that may prolong survival of patients with ESKD need to be individualized where survival benefit needs to be weighed against the cost of the procedure, complication rates and the patient’s quality of life and life expectancy. Mark Brown and Cathy Miller To date no consistent model of care has been available for supporting patients and their families on a conservative non-dialysis pathway.