Should an implantable cardioverter-defibrillator (ICD) be deactivated at the end of life?

ICD Deactivation at End of Life

Yes, ICD shock therapy should be deactivated at the end of life to prevent unnecessary suffering and distress to both patients and families. 1

The Evidence-Based Recommendation

The 2017 AHA/ACC/HRS guidelines provide Class I (strongest) recommendations that clinicians should discuss ICD shock deactivation in patients nearing the end of life from any illness, refractory heart failure, or refractory sustained ventricular arrhythmias 1. This is not optional—it is a should recommendation, meaning it applies to the vast majority of patients in these circumstances.

Why Deactivation is Critical for Quality of Life

When ICDs are not deactivated at end of life, patients and families suffer unnecessarily. The evidence is stark:

• 20% of patients receive shocks from their ICDs at the end of life 2
• In one hospice survey, half of the staff reported a deceased patient had been shocked by an ICD during the year prior 1
• Families describe watching loved ones die while being shocked repeatedly—an experience described as "blow to the chest, being kicked by a mule" 2
• These shocks cause unnecessary pain, anxiety, fear, and decreased quality of life 2

The device that once prolonged life now only prolongs the dying process and causes morbidity.

When to Have the Discussion

The guidelines specify three critical timepoints for discussing deactivation 1:

1. At initial ICD implantation - Patients should be informed that shock therapy can be deactivated at any time if consistent with their goals
2. At device replacement - Revisit the discussion during any reimplantation procedure
3. During advance care planning - Include in all advance directive discussions

Additionally, initiate discussion when:

• Patient has refractory heart failure symptoms
• Patient experiences refractory sustained ventricular arrhythmias
• Patient is nearing end of life from any other illness (cancer, dementia, multi-organ failure, etc.)
• Patient has recurrent appropriate ICD shocks 3
• Patient enters hospice or palliative care

The Current Problem: Discussions Rarely Happen

Most patients are unaware their ICD can be deactivated without surgery 1. Clinicians routinely fail to inform patients about deactivation during decision-making 1. As a result:

• Patients don't include deactivation wishes in advance directives 1
• Surrogates make decisions without prior patient input 1
• Yet when asked in hypothetical scenarios, patients can clearly identify situations where they would choose deactivation 1

How to Approach the Conversation

Use a shared decision-making approach that incorporates the patient's health goals, preferences, and values 1. Frame the discussion around:

• What matters most to the patient at this stage of illness
• Whether preventing sudden cardiac death remains aligned with their goals
• The reality that many patients prefer to "die in their sleep" rather than from other causes 1
• The distinction between the shock function (which should be deactivated) and pacing function (which may continue to provide symptom relief)

Practical Deactivation Methods

For planned deactivation:

• Arrange for device programmer to be brought to patient's location (home, hospice, skilled nursing facility) 2
• Medical personnel should perform deactivation with technical assistance from industry representatives 2
• Deactivate shock function while typically maintaining pacing/CRT function to avoid worsening symptoms 3

For emergent situations:

• Place a doughnut magnet directly over the device to immediately suspend shock function 2
• Leave the magnet in place until function is confirmed or programmer available (devices vary in response when magnet removed) 2
• All facilities caring for ICD patients should have magnets readily available 2

Documentation Requirements

The attending physician must document 2:

1. Patient (or legal surrogate) has requested deactivation
2. Patient's capacity to decide, or identification of appropriate surrogate
3. Discussion of alternative therapies if relevant
4. Discussion of consequences of deactivation
5. Specific device therapies to be deactivated
6. Family notification (if consistent with patient wishes)

Critical Distinction: Pacemakers vs ICDs

Pacemaker deactivation is ethically and legally equivalent to ICD deactivation—patients have the same right to refuse any life-sustaining therapy 2. However, pacemaker deactivation is less commonly needed because:

• Pacemakers don't cause painful shocks
• End-stage electrolyte derangements often make pacing ineffective anyway
• Pacing may provide symptom relief during the dying process

Only deactivate pacing if specifically requested by the patient or if it clearly prolongs suffering without benefit.

Common Pitfalls to Avoid

1. Waiting too long - Don't delay discussion until patient is actively dying; have it proactively during stable periods
2. Assuming patients don't want to discuss it - Research shows patients are able to identify scenarios where they'd choose deactivation when given the opportunity 1
3. Forgetting about the magnet option - In emergent situations, immediate magnet placement prevents further shocks while awaiting programmer
4. Deactivating pacing unnecessarily - CRT and pacing functions may continue to provide symptom relief; only shock function needs deactivation in most cases
5. Failing to involve palliative care - Consultation with palliative care experts is appropriate for symptom management and family support 2

The Bottom Line

ICD deactivation at end of life is not optional—it is a quality-of-care imperative. The shock function should be deactivated when it no longer aligns with patient goals and preferences, particularly when death is approaching from any cause. This prevents unnecessary suffering while respecting patient autonomy and dignity in the dying process. The conversation should happen early and often, not as a crisis intervention.