In a patient with a Do‑Not‑Resuscitate (DNR) order who has an implanted pacemaker or implantable cardioverter‑defibrillator (ICD), how should the device be managed—continue pacing, adjust settings, or deactivate?

Management of Pacemakers in Patients with DNR Orders

In patients with DNR orders and pacemakers, the pacemaker should generally remain active and continue functioning, as it does not prolong the dying process and causes no discomfort to the patient. 1, 2

Understanding the Clinical Reality

The fundamental principle guiding this recommendation is that pacemakers do not keep dying patients alive—terminal events are caused by underlying disease processes, and at the time of death, the pacemaker will ultimately fail to capture myocardial tissue regardless of its settings. 1, 2 The dying process is driven by the terminal illness itself, not prevented by cardiac pacing. 1

Key Distinctions Between DNR and Device Management

• A DNR order addresses cardiopulmonary resuscitation only—it does not automatically require deactivation of existing cardiac devices. 3
• Pacemaker pulses are painless, so the device causes no patient discomfort during the dying process. 1, 2
• The natural dying process will override pacemaker function when the patient reaches the terminal phase. 1

When Pacemaker Deactivation IS Appropriate

Despite the general recommendation to continue pacing, patients have the absolute right to refuse or request withdrawal of any medical intervention, including pacemakers. 3, 1, 2 Honoring these requests is patient-centered care and is both ethical and legal—it is not physician-assisted suicide or euthanary. 3, 4

Required Process for Deactivation

If the patient (or surrogate decision maker) requests pacemaker deactivation, the following structured approach must be followed:

Documentation Requirements:

• A written physician order for pacemaker deactivation must be obtained. 3, 1, 2
• An accompanying DNR order is mandatory—device deactivation should be accompanied by a DNR order, and both must be recorded in the medical record. 3, 1, 4, 2
• Document that the patient or surrogate requested deactivation and has decision-making capacity (or identify the appropriate legal surrogate). 3, 1, 2
• Document that consequences and alternatives were fully discussed, including the fact that death may follow immediately in pacemaker-dependent patients. 3, 1, 2

Consultation Requirements:

• Psychiatric consultation should be obtained if there is concern about impaired decision-making capacity. 3
• Ethics consultation should be sought if clinicians disagree with the deactivation request based on clinical judgment. 3
• If the clinician has conscientious objection, the patient must be referred to another clinician willing to perform the deactivation. 3

Critical Counseling Points About Pacemaker Dependency

The most important clinical distinction is whether the patient is pacemaker-dependent:

• Pacemaker-dependent patients have no adequate intrinsic rhythm and will experience immediate hemodynamic compromise when pacing stops—death may follow immediately or within minutes of deactivation. 1
• Non-pacemaker-dependent patients have adequate intrinsic rhythms, and the timing of death after deactivation is unpredictable and related to the underlying terminal illness. 1

Common Pitfall to Avoid

Do not assume all pacemaker patients are dependent—approximately 30% of pacemakers are implanted for non-Class I/IIa indications, and many patients maintain adequate intrinsic rhythms. 1 If dependency status is unclear, program the pacemaker to "off" mode during monitored observation to assess the intrinsic rhythm and hemodynamic stability. 1

Post-Deactivation Management (If Deactivation Occurs)

After pacemaker deactivation:

• Monitor closely for symptoms requiring intensification of comfort measures, particularly respiratory distress or dyspnea, as turning off the pacemaker may paradoxically lead to additional discomfort. 1, 2
• Provide comprehensive palliative care and medical support to the patient and family. 1, 2
• Offer access to clergy or chaplain according to the patient's religious beliefs. 1

Proactive End-of-Life Planning

Ideally, conversations about device management should begin at the time of device implantation or early in terminal illness, not during acute crises. 1, 2 Encourage patients to complete advance directives that specifically address device management preferences. 3, 1, 2 Healthcare systems should have established processes for device deactivation to avoid delays when requests are made. 1

Special Consideration: ICDs vs. Pacemakers

If the patient has an ICD (implantable cardioverter-defibrillator) rather than just a pacemaker, the shock function should be deactivated in hospice/terminal patients, as 20% of patients receive painful shocks at end of life. 4 The ICD shock function can be immediately deactivated by placing a doughnut magnet over the device. 4 However, this only affects the shock function—the pacing function continues and should be managed as described above. 4