Baylor University Medical Center Proceedings April 2017 - 159

have an obligation to arrange for alternative provision of care
in cases of conscientious objection that cannot be resolved by
ethical or clerical consultation.
It is important to explain to pacemaker-dependent patients
that deactivating the pacemaker function might not result in
eminent death but rather in inadequate cardiac output symptoms like dizziness and even syncopal episodes.
Disagreements may ensue between family members about
the management of a CIED when a patient's decision-making
capacity is compromised. Surrogates should usually advocate for
the patient's expressed wishes, if known, or otherwise should use
their best judgment in determining the patient's most probable
choice. Determining early on who has the health care power of
attorney and who is the next of kin can help obviate unnecessary
friction. Family meetings are necessary to address concerns and
misconceptions and often facilitate consensus, but the hospital
ethics committee may also need to be involved.
PRACTICAL CONSIDERATIONS
The eﬀect of magnet placement diﬀers by the nature of
CIED. Pacemakers respond by switching to an asynchronous
pacing mode at a ﬁxed rate depending on the manufacturer,
device model, and battery status. If magnet application on a
pacemaker site does not produce any response on the pacing rate
or mode, the reason might be a depleted pacemaker battery. Alternatively, the device might not be within the magnetic ﬁeld, as
in the case of those with deep (abdominal or submuscular) implants. In almost all pacemakers, removal of the magnet causes
the device to revert to pacing at the normal preprogrammed rate.
In ICDs, magnet application suspends antitachycardia therapy
without any eﬀect on the pacing mode (8).
In patients with a do not resuscitate (DNR) order in force,
ICD deactivation should be seriously considered. However, patients with an ICD who have a DNR directive may still beneﬁt
from ongoing ICD therapy if the arrhythmias being treated
reﬂect the primary cardiac condition and not an irreversible
secondary medical illness or if prompt ICD therapy confers the
likelihood of added survival with meaningful quality of life and
the patient concurs with this approach.
The deactivation of a CIED does not necessarily mean shutting oﬀ its diagnostic capabilities. The patient, or his or her
surrogate, needs to decide whether to keep these features on.
Some patients might prefer not to know, or not to let their
families know, what happens to their heart rhythm. In this case,
the consequences of turning oﬀ the CIED monitoring features
should be explained in detail to the patient, noting that cardiac
rhythm data will not be available to guide the treatment of any
medical condition.
There is often a misconception among patients and families
that a pacemaker will keep the patient alive when he or she
would have otherwise died from the underlying disease. Pacemakers are not resuscitative devices, and they will not keep a
dying patient alive. Most dying patients become acidotic before
cardiac arrest, which eﬀectively renders a pacemaker nonfunctional, as under such conditions, the myocardium does not
respond to the pacemaker's discharges. Thus, for most patients,
April 2017

Search medical records for
device indication and
previous interrogations

Identify device
type and model

Determine
consequences of
turning off the device

Discuss medical conditions and life
expectancy with the team of
providers
Document in patient's chart
Discuss wishes, understanding, suggested strategy,
and expectations with the patient or surrogate
Document in patient's chart

Appropriate
management

strategy

Figure 2. Suggested algorithm for data gathering, decision making, and
implementation of changes to device therapy in terminally ill patients.

an active pacemaker will not aﬀect the timing or circumstances
of death (9).
When a person with an ICD has cardiac arrest from a
shockable rhythm, the device delivers a sequence of shocks to
terminate the arrhythmia. If the device does not deliver such
shocks or if the shockable rhythm persists, external deﬁbrillation should be attempted. External deﬁbrillator electrodes
should not be placed close to the CIED site. If a person with a
pacemaker or ICD has return of spontaneous circulation after
receiving cardiopulmonary resuscitation, the device should be
interrogated at the earliest opportunity (10).
In conclusion, the management of CIEDs in terminally ill
patients can be complicated; the algorithm in Figure 2 summarizes appropriate steps for data gathering and decision making in
this situation. The concept of patient autonomy underlies both
the ethical and legal principles surrounding CIED deactivation,
and these principles have been well established. Awareness of the
practical and ethical considerations outlined above is essential
for the optimal and timely management of CIEDs in terminally
ill patients and for optimal communication between health care
providers, patients, and their families.
1.

Lampert R, Hayes DL, Annas GJ, Farley MA, Goldstein NE, Hamilton
RM, Kay GN, Kramer DB, Mueller PS, Padeletti L, Pozuelo L, Schoenfeld
MH, Vardas PE, Wiegand DL, Zellner R; American College of Cardiology;
American Geriatrics Society; American Academy of Hospice and Palliative
Medicine; American Heart Association; European Heart Rhythm Association; Hospice and Palliative Nurses Association. HRS expert consensus
statement on the management of cardiovascular implantable electronic
devices (CIEDs) in patients nearing end of life or requesting withdrawal
of therapy. Heart Rhythm 2010;7(7):1008-1026.

Pacemaker and ICD management in terminal illness

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings April 2017