When would you consider deactivating an implantable cardioverter defibrillator (ICD) in a patient who was nearing the end of their life?
The short answer is that ICD deactivation should be considered whenever a patient wants it to be considered. Even if a patient was not near the end of their life, legally and ethically, an ICD should be deactivated if the patient wants it to be deactivated.
However, the longer answer is that all patients with an ICD should have an opportunity to discuss the option of deactivation before they reach the end of their life (ie, shortly after implantation). The issue of deactivation should also be proactively discussed with a patient when their condition worsens and a good time to discuss the issue is when other preferences, such advanced directives [living wills] or a do not resuscitate (DNR) orders, are being discussed. It is not up to the physician when an ICD “should” be deactivated. The role of the physician is to make sure the patient understands the consequences of keeping it active versus deactivating it—when the patient has all of the available facts, then the decision to deactivate is up to them. The decision should be made in the context of the person’s overall goals for his or her care at that time.
What are the indications that a patient is nearing the end of their life?
Often it is not clear, and this is one of the difficult issues in discussing deactivation and one of the reasons it is so important to discuss the issue early on. Other times, though, physicians can tell as a patient’s disease course progresses (whether it is their underlying heart disease or another disease such as cancer) that the disease is overcoming the patient and therapeutic options are exhausted.
You state that a good time to discuss deactivation is when advance healthcare directives are being discussed. Would you therefore encourage patients to include their wishes on ICD deactivation in these documents and generally why in your view are such directives important?
I would definitely encourage patients to write an advanced directive, and that they include their wishes regarding ICD deactivation. This is important, as is all advanced planning relating to ICD deactivation at the end of life, to avoid potential shocks, which are painful, as a person is dying.
If a healthcare provider has ethical or moral concerns about deactivation, what should they do?
The American Medical Association (AMA) code of ethics states that a physician should not be compelled to perform an action that goes against his moral beliefs. However, our document (1) stresses that the healthcare provider should not attempt to impose his beliefs on the patient and should help direct the patient to an alternate provider who can help him.
1. Lampert et al. Heart Rhythm Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing the end of life or requesting withdrawal of therapy. Heart Rhythm 2010; 7:1008–26