In a patient with a DNR order and an ICD, should a magnet be placed over the ICD or should time be taken to discuss deactivation with a relative?

ICD Management in a Dying Patient with DNR

In a dying patient with a DNR order and an ICD, immediately place a magnet over the device to prevent painful shocks—do not delay for family discussions about formal deactivation. 1

Immediate Action: Magnet Placement

The most critical priority is preventing distressing shocks to the dying patient, which occur in 20% of patients at end of life and are described as feeling like "being kicked by a mule." 2 All ICDs can be deactivated immediately by placing a doughnut magnet directly over the device, which requires no technical expertise, no programmer, and no delay. 2, 1

Why Magnet First, Not Family Discussion

• Time is the enemy: Dying patients may receive multiple painful, distressing shocks while waiting for family discussions or formal deactivation procedures 1
• Quality of life imperative: Shocks cause significant pain, anxiety, and fear that actively harm the dying patient's quality of life 2
• Ethical and legal clarity: Patients with DNR orders have already expressed their wishes to forego life-sustaining interventions; the ICD contradicts this goal 2, 1

Practical Implementation

The magnet should be left in place continuously until magnet function is confirmed or a programmer becomes available, as devices differ in their response when the magnet is removed. 2

Key Technical Points

• Magnet placement only deactivates the shock function, not pacing 2, 1
• All facilities should have doughnut magnets on-site and readily available 2, 1
• Magnet positioning must be precise directly over the device 3

When to Involve Family

Family discussions about ICD deactivation should have occurred proactively before the patient reached the dying phase, ideally in consultation with the attending cardiologist. 2 However, when a patient is actively dying with a DNR order, the clinical imperative to prevent suffering takes precedence over delayed family consultation.

The Proper Sequence

1. Immediate: Place magnet to prevent shocks 2, 1
2. Concurrent: Inform family of the action taken and why it aligns with the patient's DNR wishes 2
3. When feasible: Arrange formal deactivation with programmer and medical personnel 2

Critical Pitfalls to Avoid

• Delaying magnet placement while seeking family permission—this is the most harmful error, as the patient may receive multiple painful shocks during the delay 1
• Confusing magnet placement with formal deactivation—the magnet is a temporary measure, but it is immediately effective and appropriate for emergency situations 2, 1
• Assuming the magnet will also disable pacing—it will not, which is generally acceptable in dying patients 2, 1
• Imprecise magnet positioning—the magnet must be placed directly over the device or it may fail to suspend therapy 3, 4

Formal Deactivation Considerations

If the patient survives beyond the immediate crisis and formal deactivation is desired, the Heart Rhythm Society recommends that medical personnel (physician or nurse) should perform the deactivation using a programmer, with technical assistance from industry-employed allied professionals. 2 However, this formal process should never delay immediate magnet placement in an actively dying patient experiencing or at risk for shocks. 1