Should implantable cardioverter-defibrillators (ICDs) be removed or deactivated in patients with terminal illnesses receiving hospice care?

ICD Deactivation in Hospice Patients

ICDs should be deactivated (not physically removed) in hospice patients who request it, and this discussion should be proactively initiated by clinicians as part of end-of-life care planning. 1

Ethical and Legal Framework

Deactivating ICDs in terminally ill patients is both ethical and legal, and is not considered physician-assisted suicide or euthanasia. 1 The ACC/AHA/HRS guidelines establish clear consensus that:

• ICDs are life-sustaining treatments that patients have the right to refuse or withdraw 1
• Ethics and law make no distinction between withholding and withdrawing treatments 1
• Imposing device therapy on patients who do not want it is unethical and illegal (battery) 1

Clinical Rationale for Deactivation

The evidence strongly supports proactive deactivation discussions because:

• 20% of ICD patients receive shocks at the end of life, causing significant pain, anxiety, and distress to both patients and families 2
• Some patients experience uncomfortable defibrillations throughout the dying process, including moments before death 1
• In one study, 64% of hospice programs reported patients receiving unwanted shocks, and 86% reported some adverse experience with ICDs 3
• Patients and families fear that devices will prolong the dying process 1

Deactivation vs. Physical Removal

The question asks about "removal," but the correct approach is deactivation, not surgical extraction. 1, 2 Physical removal would require surgery and is unnecessary. Deactivation can be accomplished:

• Immediately with a magnet: All ICDs can be deactivated by placing a doughnut magnet directly over the device, which should be left in place 1, 2
• Formally with a programmer: For permanent deactivation, the device should be reprogrammed to inactive status 1

Required Process for Deactivation

The ACC/AHA/HRS guidelines mandate a structured approach 1:

1. Patient Discussion and Documentation

• The patient (or surrogate if lacking capacity) must be fully informed of consequences and alternatives 1
• Document the conversation, patient capacity, and specific therapies to be deactivated in the medical record 1

2. Concurrent Orders

• Device deactivation must be accompanied by a DNR order 1
• Both orders must be recorded in the patient's medical record 1

3. Consultation Requirements

• Psychiatric consultation if the patient is thought to have impaired decision-making capacity 1
• Ethics consultation if clinicians disagree with the deactivation request 1

4. Conscientious Objection

• If the clinician has personal beliefs prohibiting device deactivation, the patient must be referred to another clinician 1

Palliative Care Integration

Patients must receive comprehensive palliative measures to manage symptoms that may emerge from device deactivation, particularly if pacing therapy is withdrawn 1, 2:

• Pharmacologic management of symptoms including anxiety, dyspnea, and pain 1, 2
• Family emotional support and expectation-setting 1, 2
• Consider formal palliative care consultation for symptom management uncertainty 1

Critical Distinction: Pacemaker vs. ICD Function

A common pitfall is failing to distinguish between shock therapy and pacing therapy 1, 2:

• Deactivating ICD shock function is clearly appropriate and causes no immediate physiologic change 1, 2
• Deactivating pacing in pacemaker-dependent patients will result in death, requiring more careful consideration 1
• Magnet placement only deactivates shock function, not pacing 2

Proactive Discussion Requirement

The ACC/AHA guidelines recommend that patients with refractory end-stage heart failure and ICDs should receive information about the option to deactivate the defibrillator 1:

• These discussions should occur before the terminal phase, ideally at device implantation 1
• Patients should complete advance directives that specifically address device management 1
• Only 1 of 91 patients in one study had end-of-life implications documented during ICD consent 4

Common Pitfalls to Avoid

• Delay in deactivation: Dying patients may receive multiple painful shocks while waiting for formal procedures 2, 3
• Lack of screening: Only 43% of hospice programs routinely screen for ICDs 3
• Inadequate policies: Only 38% of hospice programs have ICD management policies 3
• Confusing deactivation with assisted suicide: This is legally and ethically incorrect 1

Practical Implementation in Hospice Settings

For patients in hospice facilities without on-site electrophysiology expertise 1:

• The attending physician should contact the physician responsible for the device 1
• Industry-employed allied professionals can bring a programmer to the bedside 1
• Medical personnel should perform deactivation with technical assistance from industry representatives 1
• All facilities should have doughnut magnets readily available for emergency deactivation 2