Baylor University Medical Center Proceedings April 2017 - 157


Practical and ethical considerations in the management
of pacemaker and implantable cardiac defibrillator devices
in terminally ill patients
Mina M. Benjamin, MBBCh, and Christine A. Sorkness, MD

More than 4.5 million people worldwide live with an implanted pacemaker, including >3 million in the USA alone. Also, >0.8 million people in
the USA have an implantable cardioverter defibrillator (ICD). Knowing the
principles of managing these devices towards the end of life is important,
as the interruption of their function may have serious consequences.
This article provides health care providers who are not specialized in
cardiac electrophysiology with an introduction to the general principles
of management of pacemakers or ICD devices towards the end of life,
with a suggested algorithm for approaching this process. Also discussed
are pertinent ethical and practical considerations in deciding on and
implementing a management strategy for these devices during terminal
illnesses.

T

he nurse called the on-call cardiology fellow at 1:00 am
asking him to deactivate the cardiac device of a patient
pursuing hospice. The patient was a 78-year-old man,
admitted with an acute kidney injury on top of chronic
kidney disease. The device identiﬁcation card carried by the
patient indicated that he had an implantable cardioverter
deﬁbrillator (ICD) for primary prevention after a myocardial infarction. The patient was deemed in need of urgent
hemodialysis during this hospitalization, but he was hesitant
because of his short life expectancy of 6 to 12 months due
to metastatic prostate cancer. The palliative care service was
consulted. The patient decided at night, after consulting with
his family, that he would rather pursue hospice. Device interrogation showed periods of heart block of varying length, but
no fatal arrhythmias. The patient was not interested in any
therapies that would prolong his life and requested device
deactivation. The patient's daughter stated that she was worried her father was "not thinking straight" and that deactivating the pacemaker device would make him feel bad. What
should be done with the device monitoring, deﬁbrillating,
and pacing functions? Unfortunately, these case scenarios
are not uncommon.
This article is intended to provide health care providers who
are not specialized in cardiology or medical ethics with brief
insights into the principles and ethical and practical considerations of pacemakers or ICD device management towards the
end of life.
Proc (Bayl Univ Med Cent) 2017;30(2):157-160

GENERAL CONSIDERATIONS
Interruption of cardiovascular implanted electronic device
(CIED) function, especially in pacemaker-dependent patients,
may have immediate and serious consequences. In 2010, the
Heart Rhythm Society, in association with the European Heart
Rhythm Association, released an expert consensus statement on
the management of CIEDs in patients nearing the end of life or
requesting withdrawal of therapy (1). This statement includes an
outline of the practical, ethical, legal, and religious principles of
managing CIEDs towards the end of life. Basically, patients (or
their legally designated surrogates) can request discontinuation
of any medical or device treatment. Moreover, it is not necessary
for patients to be terminally ill to make these requests.
Several factors aﬀect the strategy to recommend to patients
towards the end of life. Having clear answers to these questions eases many of the potential practical, ethical, and legal
dilemmas for health care providers. First and foremost, the
health care provider should determine if the patient is cognitively competent and able to comprehend the consequences of
diﬀerent changes in device settings. Ideally, discussions about
device management in the event of terminal illness should start
at the time of implantation. Unfortunately, in real life, only a
minority of patients are asked about their wishes at the time
of implantation. It is of utmost importance to also discuss this
issue when patients with CIEDs are admitted with conditions
that could lead to rapid deterioration in their health, especially
their cognitive status.
Next, the type of device needs to be identiﬁed, as devices
may vary considerably in their monitoring/therapy capabilities.
Each patient is provided with an identiﬁcation card, with information about the device and company contact information,
at the time of implantation. If the patient does not carry an
identiﬁcation card and the medical records are unavailable, other
methods can be used. A chest x-ray provides information about
the number and position of the intracardiac leads (Figure 1). A
From the Divisions of Cardiovascular Medicine (Benjamin) and Allergy, Pulmonary,
and Critical Care Medicine (Sorkness), Department of Medicine, University of
Wisconsin Hospital, Madison, Wisconsin.
Corresponding author: Mina M. Benjamin, MBBCh, University of Wisconsin
Hospital, 2961 Index Road, Apt. 115, Fitchburg, WI 53792 (e-mail: mehanni@
wisc.edu).
157

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