Should a pacemaker be removed in a patient with a terminal illness in hospice care?

Pacemaker Management in Hospice Patients

In most hospice patients, pacemakers should NOT be routinely removed or deactivated, as they do not prolong the dying process and cause no discomfort—reassurance and turning off cardiac monitoring is usually all that is needed. 1

Understanding the Clinical Reality

The 2018 ACC/AHA/HRS guidelines make clear that pacemakers do not keep dying patients alive because terminal events are typically caused by the underlying disease (cancer, organ failure, etc.), and at the time of death, the pacemaker will ultimately fail to capture myocardial tissue, rendering it irrelevant. 1, 2

Key clinical facts:

• Pacemaker pulses are painless and cause no discomfort to the dying patient 1, 2
• Terminal illness progression is driven by the underlying disease, not prevented by pacing 2
• The natural dying process will override pacemaker function 2
• Patients and families often wrongly assume pacemakers prolong suffering, but this is a misconception that requires correction 1

When Deactivation May Be Appropriate

If the patient or their legal surrogate specifically requests pacemaker deactivation after informed discussion, this request should be honored as it represents withdrawal of life-sustaining treatment, not physician-assisted suicide. 1

Patient Rights (ACC/AHA/HRS Position)

• Patients have the absolute right to refuse or request withdrawal of any medical intervention, including pacemakers 1
• Honoring these requests is patient-centered care and ethically/legally permissible 1
• Ethics and law make no distinction between withholding and withdrawing treatments 1

Critical Counseling Before Deactivation

Before proceeding with deactivation, physicians must clarify the expected consequences:

For Pacemaker-Dependent Patients

• Death may follow immediately after cessation of pacing therapy 1, 2
• These patients have no adequate intrinsic rhythm and require continuous pacing 2

For Non-Pacemaker-Dependent Patients

• The timing of death may be unpredictable and not necessarily hastened 1, 2
• Many patients maintain adequate intrinsic rhythms 2

Potential Paradoxical Harm

Turning off a pacemaker may paradoxically lead to additional discomfort (respiratory distress, dyspnea) requiring intensification of comfort measures. 1, 2 This is a critical counseling point that contradicts the common assumption that deactivation always improves comfort.

Required Documentation and Procedures (If Deactivation Requested)

The ACC/AHA/HRS guidelines mandate specific documentation:

• Written physician order for pacemaker deactivation 1, 2
• Accompanying DNR order 1, 2
• Confirmation that patient/surrogate requested deactivation 1, 2
• Documentation of patient capacity or identification of appropriate legal surrogate 1, 2
• Documentation that consequences and alternatives were discussed 1, 2
• Psychiatric consultation if impaired decision-making capacity is suspected 1
• Ethics consultation if clinicians disagree with the request 1

Post-Deactivation Management

If deactivation proceeds, intensive monitoring and support are essential:

• Monitor closely for symptoms requiring intensification of comfort measures, particularly respiratory distress 1, 2
• Provide palliative care and medical support to patient and family 1, 2
• Offer access to clergy/chaplain according to patient's religious beliefs 1, 2

Conscientious Objection

If the clinician has personal beliefs prohibiting device deactivation, the patient should be referred to another clinician willing to perform the procedure. 1

Proactive End-of-Life Planning

Best practice involves early conversations:

• Discussions about device management should ideally begin at the time of device implantation or early in terminal illness 1, 2
• Encourage patients to complete advance directives that specifically address device management 1, 2
• Healthcare systems should have established processes for device deactivation 2

Common Pitfalls to Avoid

• Do not assume pacemakers prolong the dying process—this is the most common misconception requiring correction 1, 2
• Do not routinely deactivate pacemakers without specific patient/surrogate request, as deactivation may cause harm rather than benefit 1, 3
• Do not confuse pacemaker management with ICD management—ICDs deliver painful shocks and have clearer indications for deactivation in dying patients 1, 4
• Do not proceed without determining pacemaker dependency status, as this dramatically affects the clinical trajectory 2