How do you deactivate an Automated Implantable Cardioverter-Defibrillator (AICD) in a dying patient?

Deactivating an AICD in a Dying Patient

Place a doughnut magnet directly over the device to immediately deactivate the shock function—this is the fastest and most practical method for emergent situations in dying patients. 1

Immediate Practical Steps

Emergency Deactivation with Magnet

• All ICDs can be deactivated by placing a doughnut magnet directly over the device, which disables the defibrillator function without requiring a programmer or technical expertise 1
• The magnet should be left in place until magnet function is confirmed or a programmer is available, as devices differ in their response when the magnet is removed 1
• All facilities caring for patients with ICDs should have doughnut magnets on-site and readily available for emergency deactivation 1
• The magnet only deactivates the shock function; pacing function will continue, which is typically appropriate for comfort 1

Important Caveat About Magnets

While doughnut magnets are the standard, research shows that commonly available magnetic sources (ceramic magnets, computer hard drives) may potentially deactivate an ICD in urgent situations when a delay in reprogramming is anticipated, though this is speculative and should only be considered when proper equipment is unavailable 2

Formal Deactivation with Programmer

When to Use This Method

• For patients well enough to travel to a clinic, an outpatient visit with programming capability may be acceptable 1
• For patients in facilities without electrophysiology expertise who cannot travel, arrange for a programmer to be brought to the bedside 1

The Process

• Medical personnel (physician or nurse) should perform the deactivation using the programmer, with technical assistance from industry-employed allied professionals (IEAPs) who represent the device manufacturer 1
• The IEAP should always act under direct supervision of medical personnel except in rare emergent situations when medical personnel are unavailable 1
• Communication between an electrophysiologist, facility personnel, and IEAPs is imperative for appropriate deactivation 1

Critical Pre-Deactivation Considerations

Required Documentation and Discussion

Before deactivation, confirm the following 1:

• The patient (or legal surrogate) has requested device deactivation 1
• The capacity of the patient to make the decision, or identification of the appropriate surrogate 1
• Alternative therapies have been discussed if relevant 1
• Consequences of deactivation have been discussed, including that death may follow rapidly, particularly in pacemaker-dependent patients 1
• The specific device therapies to be deactivated (shock function vs. pacing function) 1
• Notification of family if consistent with patient's wishes 1

Why This Matters for Quality of Life

• Twenty percent of patients receive shocks from their ICDs at the end of life, causing distress to both patients and families 1
• Shocks have been described as "blow to the chest, being kicked by a mule", and the pain, anxiety, and fear associated with shocks significantly decrease quality of life 1
• When ICDs are not deactivated at the end of life, patients and families suffer unnecessarily, with families watching loved ones die while being shocked repeatedly 1
• In one survey of hospice staff, half noted that a deceased patient had been shocked by an ICD during the year prior to the survey 1

Ethical and Legal Framework

Patient Rights

• Patients have the same right to deactivate an ICD as any other life-sustaining therapy, both ethically and legally 1
• The AHA/ACC/HRS guidelines (2017) provide Class I recommendations that clinicians should discuss ICD shock deactivation in patients with refractory heart failure symptoms, refractory sustained ventricular arrhythmias, or nearing the end of life from other illness 1, 3
• ICD shock therapy can be deactivated at any time if it is consistent with the patient's goals and preferences 1, 3

The Communication Gap

• Many patients are unaware that their ICD can be deactivated without surgery, and clinicians do not routinely inform patients about this option 1
• Patients often do not include wishes about deactivation in advance care planning documents, resulting in surrogates making decisions without prior patient discussions 1
• This discussion should occur at the time of initial ICD implantation, at reimplantation, and during preparation of advance care plans 1

Palliative Care Integration

Essential Support Measures

• Establish palliative care interventions and provide patient and family support before and after deactivation 1
• Patients must be offered the full range of palliative measures to treat symptoms associated with progression of their underlying illness, including any new symptoms that may emerge from cessation of device therapy 1
• Patients may benefit significantly from pharmacological measures that minimize symptoms, particularly if pacing therapy is also being withdrawn 1
• Setting expectations for family members regarding the consequences and uncertainties of deactivation is imperative 1

Practical Considerations

• It may be especially important to have a member of the clergy present for patients with a well-defined faith tradition 1
• Formal consultation with palliative care experts is particularly appropriate when there is uncertainty about symptom management before and after device deactivation 1
• It is generally appropriate to discontinue rhythm monitoring when pacing therapy is withdrawn 1

Common Pitfalls to Avoid

The Urgency Problem

The most critical pitfall is delay—dying patients may receive multiple painful shocks while waiting for formal deactivation procedures 1. This is why having a doughnut magnet immediately available is essential 1.

The Pacing Distinction

Understand that magnet placement only deactivates the shock function, not pacing 1. If the patient is pacemaker-dependent and pacing deactivation is also desired, a programmer is required 1.

The Timing of Discussion

Do not wait until the patient is actively dying to have this conversation 1. The British Heart Rhythm Society emphasizes that discussions should occur proactively to prevent the risk of painful shocks and delayed natural death 4.