What to do with a patient's dual (dual-chamber) pacemaker at end of life?

Management of Dual-Chamber Pacemakers at End of Life

In most cases, pacemaker deactivation is unnecessary at end of life—reassurance of patients and families combined with turning off cardiac monitoring is all that is needed, as pacemakers generally do not prolong the dying process. 1

Understanding the Clinical Reality

The ACC/AHA/HRS guidelines clarify a critical misconception: pacemakers do not keep dying patients alive because terminal events are typically caused by other clinical conditions (cancer, organ failure), and at the time of death, the pacemaker will ultimately fail to capture myocardial tissue, rendering it irrelevant. 1

Key Clinical Facts:

• Pacemaker pulses are painless, so the device causes no discomfort to the dying patient 1
• Terminal illness progression is driven by the underlying disease, not prevented by pacing 1
• The natural dying process will override pacemaker function 1

When Deactivation IS Requested

If the patient (with decision-making capacity) or their legally defined surrogate explicitly requests deactivation after understanding the consequences, proceed with the following protocol:

Legal and Ethical Framework:

• Patients have the absolute right to refuse or request withdrawal of any medical intervention, including pacemakers 1
• This is NOT physician-assisted suicide—it is patient-centered care and withdrawal of life-sustaining treatment 1
• If you have religious or ethical objections, refer to another physician; you should not be forced to perform deactivation 1

Required Documentation:

1. Written physician order for pacemaker deactivation 1
2. Accompanying do-not-resuscitate (DNR) order 1
3. Confirmation that patient/surrogate requested deactivation 1
4. Documentation of patient capacity OR identification of appropriate legal surrogate 1
5. Documentation that consequences of deactivation were discussed 1

Critical Counseling Points Before Deactivation:

For pacemaker-dependent patients:

• Death may follow immediately after cessation of pacing 1

For non-pacemaker-dependent patients:

• The dying process may be unpredictable in timing 1
• Turning off the pacemaker may paradoxically lead to additional discomfort (respiratory distress, dyspnea) 1

Post-Deactivation Management:

• Monitor closely for symptoms requiring intensification of comfort measures, particularly respiratory distress 1
• Provide palliative care and medical support to patient and family 1
• Offer access to clergy/chaplain according to patient's religious beliefs 1

Proactive End-of-Life Planning

Ideally, conversations about device management should begin at the time of device implantation or early in terminal illness. 1

• Encourage patients to complete advance directives that specifically address device management 1
• Healthcare systems should have established processes for device deactivation 1

Common Pitfalls to Avoid

Pitfall #1: Assuming Deactivation is Always Necessary

The most common error is believing that pacemakers prolong suffering—they typically do not, and deactivation may cause more harm than benefit 1, 2

Pitfall #2: Confusing Pacemakers with ICDs

Physicians report more discomfort deactivating pacemakers than defibrillators, though the ethical framework is identical 1, 3

Pitfall #3: Inadequate Symptom Monitoring Post-Deactivation

Failure to anticipate and manage respiratory distress or other discomfort that may arise after deactivation 1

Pitfall #4: Proceeding Without Proper Documentation

Missing any of the five required documentation elements creates legal and ethical vulnerability 1

The Shared Decision-Making Conversation

Use this framework when discussing with patients/families:

1. Clarify the misconception: "The pacemaker is not keeping your loved one alive—the terminal illness will progress regardless" 1

2. Explain the reality: "The pacemaker pulses are painless, and turning it off may actually cause more discomfort without changing the timing of death" 1

3. Offer reassurance: "We can turn off the cardiac monitor so you don't see the heart rhythm, which may provide more peace" 1

4. If deactivation is still desired: Proceed with full informed consent and documentation as outlined above 1