What Happens to a Pacemaker When Someone Dies
When a person dies, the pacemaker continues to deliver electrical impulses until the myocardial tissue becomes unresponsive and can no longer be captured, at which point the device becomes functionally irrelevant to the dying process. 1, 2
The Physiological Reality at End of Life
Pacemakers do not keep dying patients alive because terminal events are typically caused by underlying clinical conditions such as cancer, sepsis, or multi-organ failure—not by the absence of cardiac pacing. 1, 2
What Actually Occurs During the Dying Process
The pacemaker continues to fire electrical impulses as programmed, but at the time of death, the myocardial muscle ultimately fails to respond to these impulses (loss of capture), rendering the device irrelevant. 1, 2
Terminal electrolyte derangements (hyperkalemia, acidosis) that occur during the dying process make pacing progressively ineffective regardless of whether the device is functioning. 1
The natural dying process overrides pacemaker function—the device cannot prevent death from the underlying terminal illness. 2
Pacemaker pulses are completely painless, so the device causes no discomfort to the dying patient even as it continues to function. 1, 2
Common Misconceptions That Require Counseling
Families frequently fear that pacemakers will prolong the dying process and suffering, but this is a misconception. 1, 2
In most cases, pacemaker deactivation is unnecessary—simply turning off cardiac monitoring and providing reassurance to the family may be all that is needed. 1
The terminal illness progression is what determines the timing of death, not the presence or absence of pacing. 1, 2
When Deactivation Is Requested
If a patient or their legally defined surrogate requests pacemaker deactivation, this is their absolute right under ACC/AHA/HRS guidelines. 1, 2
Immediate Consequences Depend on Pacemaker Dependency
For pacemaker-dependent patients (those with complete heart block, no escape rhythm, or post-AV junction ablation):
- Death may follow immediately or within minutes after cessation of pacing therapy. 1, 2
- These patients have no adequate intrinsic rhythm and will experience immediate hemodynamic collapse. 2
For non-pacemaker-dependent patients:
- The timing of death is unpredictable and may not be related to device deactivation. 1, 2
- Many patients maintain adequate intrinsic rhythms, as approximately 30% of pacemakers are implanted for non-Class I/IIa indications. 1, 2
Critical Caveat About Deactivation
Turning off a pacemaker may paradoxically lead to additional discomfort such as respiratory distress or dyspnea, requiring intensification of comfort care measures. 1, 2
Required Documentation for Deactivation
The ACC/AHA/HRS guidelines mandate specific documentation: 1, 2
- Written physician order for pacemaker deactivation
- Accompanying do-not-resuscitate (DNR) order
- Confirmation that the patient or legal surrogate requested deactivation
- Documentation of patient capacity or identification of appropriate legal surrogate
- Documentation that consequences of deactivation were discussed
- Close monitoring for symptoms requiring palliative interventions
Post-Mortem Device Considerations
For Cremation
Pacemakers must be removed before cremation because they can explode when heated, causing structural damage to cremation facilities and potential injury to staff. 3
- About half of all crematoria in the UK have experienced pacemaker explosions. 3
- Doctors who sign cremation forms have a legal obligation to document whether a pacemaker is present and whether it has been removed. 3
- Newer leadless pacemakers (Micra™) appear not to cause explosions during cremation in small case series, though this remains an evolving area. 4
For Burial
- No removal is required for burial—the device can remain in place without any safety concerns. 3
Ethical and Legal Framework
Withdrawal of pacemaker therapy with informed consent is not physician-assisted suicide but rather patient-centered care and withdrawal of life-sustaining treatment. 1, 2
Patients with decision-making capacity, or their legally defined surrogate, have the right to refuse or request withdrawal of any medical intervention, including pacemakers, regardless of whether withdrawal would result in death. 1, 2
These decisions should be undertaken using principles of shared decision-making between patients (or surrogates) and physicians. 1
Practical Clinical Approach
Ideally, conversations about device management at end of life should begin at the time of device implantation or early in terminal illness, not in the acute dying phase. 2
- Encourage patients to complete advance directives that specifically address device management. 2
- Healthcare systems should have established processes for device deactivation to avoid physician discomfort with these conversations. 1
- Provide palliative care and medical support to the patient and family, with access to clergy or chaplain according to the patient's religious beliefs. 1, 2