Heart devices can be turned off near end of life

Physicians can deactivate implanted defibrillators and pacemakers when terminally ill patients request it, according to new guidelines from the Heart Rhythm Society.

By — Posted May 31, 2010

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

It is legal and ethical to honor patient requests to deactivate implanted cardiac devices, and physicians should take the initiative in talking with terminally ill patients and their families about turning off the devices, according to a new expert panel consensus statement released in May.

Implantable cardioverter-defibrillators, or ICDs, can impose a particularly heavy burden on terminally ill patients, continuing to send electrical shocks as the patient dies.

"His defibrillator kept going off," one family member of a dying patient told the authors of a study in the Dec. 7, 2004, Annals of Internal Medicine. "It went off 12 times in one night."

The phenomenon of an active ICD sending shocks in dying patients is not rare, said Rachel J. Lampert, MD, lead author of the consensus statement by the Heart Rhythm Society. The group represents more than 5,100 physicians specializing in cardiac pacing and cardiac electrophysiology.

"We know from data from our own institution that for about 20% of patients with ICDs the defibrillators go off in the days or weeks or hours before they die," said Dr. Lampert, associate professor of medicine at the Yale University School of Medicine in Connecticut. "ICD shocks save countless lives, and that's a wonderful thing, but when people are dying, the shocks are painful. The shocks aren't going to save them from cancer."

Nearly three-fifths of hospices reported patients getting shocked by their ICDs within the past year, said a March 2 Annals of Internal Medicine study. Only 10% of the 414 hospices surveyed had policies on deactivating ICDs, and 58% of the terminally ill patients who received shocks did not have their devices turned off.

The Heart Rhythm Society panel, which included representatives from the American College of Cardiology, the American Geriatrics Society, the American Academy of Hospice and Palliative Medicine, and the American Heart Assn., set out to address the problem by clarifying the legal and ethical status of deactivating cardiac devices. The consensus statement also advises physicians on how to communicate with patients and families about whether to turn off a device.

There are no court cases dealing directly with deactivating heart devices, but the legal and ethical principle that patients and their surrogates have the right to refuse care is solidly grounded, said panel member George J. Annas.

"The closest and most controversial cases are the feeding tube cases. When you take out the feeding tube, you know the patient is going to die," said Annas, chair of the Dept. of Health Law, Bioethics & Human Rights at Boston University School of Public Health. "Every court has looked at these cases and said, 'It's medical technology.' You can refuse a ventilator, you can refuse a feeding tube, you can refuse anything."

Patients have the right to refuse care, said Richard A. Zellner, a retired lawyer who served as the panel's patient representative. He had five implanted heart devices over 14 years before getting a heart transplant in 2006.

"The patient has a right to say, 'I don't want any more treatment,' " said Zellner, an adjunct lecturer in the Case Western Reserve University Dept. of Bioethics in Ohio. "When the patient says, 'I've had enough,' that's enough."

Assisted suicide?

The consensus on deactivating cardiac devices is not universal, however, as Zellner discovered personally. He said he had trouble getting doctors caring for his mother to turn off her pacemaker, which she had implanted at the age of 99.

At 101, she fell into an unresponsive "state of nonbeing," Zellner said. His mother was pacemaker-dependent, meaning that if the pacing function of her device was turned off, she would likely die quickly.

"I could not find the electrophysiologist who implanted the device," Zellner said. She eventually died 18 months later, in 2004.

The consensus statement does not distinguish between ICDs and pacemakers, saying that just as a patient has a right to refuse to have a device implanted, the patient also has a right to have the device turned off, even if that results in death. Such an act does not constitute physician-assisted suicide, the panel concluded.

"It is, literally, the difference between refusing treatment -- which patients have an absolute right to do regardless of what the consequences are -- and asking the physician to do something like a lethal injection," Annas said. "There is the question of causation -- what causes the death? It's the underlying disease, not a gun or a knife. And what's the intent? The doctor's wish is not to kill the patient, but to stop that treatment."

Many physicians are uneasy about turning off pacemakers. More than one in five Heart Rhythm Society members refused a terminally ill patient's request to deactivate a pacemaker, said a May 2008 study in Pacing and Clinical Electrophysiology.

"It may seem too much like physician-assisted suicide," said G. Neal Kay, MD, a panel member and director of clinical cardiac electrophysiology at the University of Alabama at Birmingham Hospital. "Not that that's what it is, but it could certainly make one feel uncomfortable that you're crossing that line."

The consensus statement recognizes that some physicians may believe it is wrong to deactivate pacemakers in pacemaker-dependent patients and says they should refer the patient to another doctor if so.

Doctors should start the discussion about potential deactivation early, Dr. Kay said.

"When the decision is made to implant a device, the physician owes it to the patient to at least discuss what the circumstances are when one might consider deactivating the device in the future," he said.

Back to top


How to communicate with dying patients

Physicians should talk with dying patients with implanted cardiac devices about the benefits and burdens of keeping the devices turned on, an expert panel said in May. When speaking with patients and their families about the matter, doctors should:

  • Determine what the patient and family know about the patient's illness.
  • Establish what the patient and family know about the role the cardiac device plays in the patient's health, both now and in the future.
  • Ascertain what additional information the patient and family want to know about the patient's illness.
  • Correct or clarify any misunderstandings about the current illness and possible outcomes, including the role of the cardiac device.
  • Determine the patient's and family's overall goals of care and desired outcomes.
  • Work to tailor treatments and management of the cardiac device to the patient's stated goals.

Source: "Expert Consensus Statement on Management of CIEDs," Heart Rhythm Society, May 14 (link)

Back to top

External links

"Expert Consensus Statement on Management of CIEDs," Heart Rhythm Society, May 14 (link)

"Brief Communication: Management of Implantable Cardioverter-Defibrillators in Hospice: A Nationwide Survey," abstract, Annals of Internal Medicine, March 2 (link)

"Deactivating Implanted Cardiac Devices in Terminally Ill Patients: Practices and Attitudes," abstract, Pacing and Clinical Electrophysiology, May 2008 (link)

"Management of Implantable Cardioverter Defibrillators in End-of-life Care," abstract, Annals of Internal Medicine, Dec. 7, 2004 (link)

"Position Statement on the Care of Hospice Patients with Automatic Implantable Cardioverter-Defibrillators," National Hospice and Palliative Care Organization, May 2008 (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn