From the Guidelines
Deactivating a permanent artificial cardiac pacemaker in a palliative care patient should be approached as a medical and ethical decision requiring careful consideration, with the protocol beginning with a thorough discussion between the healthcare team, patient (if capable), and family about the goals of care, ensuring informed consent is documented, as stated in the 2019 ACC/AHA/HRS guideline 1. The decision to deactivate a pacemaker should be made by the patient or their legally defined surrogate, in collaboration with the healthcare team, using the principles of shared decision-making, and should be based on the patient's individual circumstances and goals of care. Key considerations in the deactivation process include:
- Ensuring informed consent is documented
- Consulting a cardiologist or cardiac device specialist to perform the actual deactivation
- Aligning the timing of deactivation with the patient's end-of-life care plan
- Preparing appropriate symptom management medications in advance, such as morphine or midazolam
- Monitoring the patient closely after deactivation to ensure comfort and adjusting medication doses as needed. The deactivation process itself is painless and can be performed at the bedside, and it is essential to respect patient autonomy while providing compassionate end-of-life care, recognizing that pacemaker deactivation is ethically distinct from euthanasia, as it represents the withdrawal of a medical intervention rather than actively hastening death, as emphasized in the 2019 ACC/AHA/HRS guideline 1. Additionally, the 2020 European Association for Palliative Care task force expert position statement highlights the importance of advance care planning, addressing ethical dilemmas, and adjusting medical therapy in the care of patients with heart failure, including those with implantable cardiac devices 1. Overall, the protocol for deactivating a pacemaker in a palliative care patient requires careful consideration of the patient's individual needs and circumstances, and should be guided by the principles of patient-centered care and respect for patient autonomy.
From the Research
Protocol for Deactivating a Pacemaker in Palliative Care
The protocol for deactivating a pacemaker in a patient with palliative care needs involves several considerations, including:
- Patient education and informed consent regarding the risks, benefits, and alternatives to deactivation 2
- Discussion of the patient's values, goals, and preferences for end-of-life care 2, 3
- Assessment of the patient's medical condition and prognosis 4, 5
- Consideration of the potential impact of deactivation on the patient's quality of life and survival 4, 5
Deactivation Procedure
The deactivation procedure itself is typically performed by a cardiologist or other qualified healthcare professional, and may involve:
- Programming the pacemaker to cease functioning 4
- Removing or disabling the pacemaker leads 6
- Providing ongoing care and support to the patient and their family 5, 3
Ethical Considerations
The decision to deactivate a pacemaker raises ethical considerations, including:
- The patient's right to refuse treatment and autonomy in decision-making 2
- The potential for deactivation to hasten or prolong the patient's death 4, 6
- The role of palliative care in supporting the patient's quality of life and alleviating suffering 5, 3
Palliative Care Involvement
Palliative care consultation may be beneficial in supporting patients with pacemakers and their families, particularly in addressing: