When should an Implantable Cardioverter-Defibrillator (ICD) be deactivated?

When to Deactivate an Implantable Cardioverter-Defibrillator (ICD)

An ICD should be deactivated in patients with refractory heart failure symptoms, refractory sustained ventricular arrhythmias, or those nearing the end of life from other illnesses, after discussing the patient's goals and preferences. 1

Key Scenarios for ICD Deactivation

ICD deactivation should be considered in the following clinical situations:

1. End-of-life care:

   • Patients with terminal illness (cardiac or non-cardiac)
   • Patients receiving hospice or palliative care
   • Patients with DNR orders

2. Refractory cardiac conditions:

   • Uncontrollable ventricular arrhythmias causing frequent shocks
   • End-stage heart failure not responding to optimal medical therapy

3. Patient preference:

   • When a fully informed patient requests deactivation
   • When continued ICD therapy conflicts with the patient's goals of care

Timing of Deactivation Discussions

Discussions about potential ICD deactivation should occur at several key timepoints:

• At initial implantation - Patients should be informed that deactivation is possible in the future 1
• During routine device follow-up - Particularly for patients with progressive illness
• At the time of device replacement - When battery depletion requires generator change
• With significant clinical deterioration - When prognosis worsens
• When transitioning to hospice/palliative care - Before symptoms become severe

Clinical Approach to Deactivation

1. Assess clinical status and prognosis

   • Evaluate disease progression and estimated life expectancy
   • Consider consultation with palliative care specialists when appropriate

2. Conduct shared decision-making discussion

   • Explain that deactivation prevents painful shocks during the dying process
   • Clarify that deactivation is not euthanasia or physician-assisted suicide 1
   • Document the discussion in the medical record

3. Implement deactivation when appropriate

   • Ensure a DNR order accompanies the deactivation order 1
   • Arrange for device programming by qualified personnel
   • Consider remote deactivation options when patients are distant from implanting centers

Important Considerations

• Partial vs. complete deactivation: Often only the shock function is deactivated while pacing functions are maintained
• Ethical framework: Deactivation is ethically permissible as it represents withdrawal of treatment, not causing death 1
• Avoiding unnecessary suffering: Without deactivation, up to 25% of patients receive painful shocks in their final 24 hours of life 2
• Surrogate decision-making: When patients lack capacity, surrogates often make deactivation decisions without prior patient input 1

Common Pitfalls to Avoid

1. Delaying discussions until crisis: Initiate conversations early while patients have decision-making capacity
2. Assuming all healthcare providers understand deactivation: Many non-cardiac providers may be unfamiliar with ICD management
3. Failing to document preferences: Include deactivation preferences in advance directives
4. Not addressing family concerns: Family members may misinterpret deactivation as "giving up"
5. COVID-19 complications: Patient isolation policies may impede communication - use video technology when necessary 3

Despite clear guidelines recommending discussions about deactivation, studies show that over half of patients with ICDs who are dying have not been offered the choice of deactivation 3. Proactive, compassionate discussions about ICD management at the end of life are essential to prevent unnecessary suffering and align care with patients' goals and values.