Withdrawing Implantable Defibrillator Shock Therapy in Terminally Ill Patients

2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

“…Furthermore, published experience with deactivation of devices is limited. 487 There is general consensus regarding the ethical and legal permissibility of deactivating ICDs in dying patients who request deactivation. 488 However, caregivers involved in device management generally make a distinction between deactivating a pacemaker and deactivating an ICD or CRT device.…”

Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated?

“…[1][2][3][4][5][6][7] Of these, autonomy is paramount for competent adults because of their politically sanctioned right to live by their values. 5,8 Based on personal preferences and goals, an informed patient, with the requisite mental capacity for decisionmaking, can refuse treatment, including life-sustaining interventions. 2,4,6 No ethical or legal distinction exists between withholding and withdrawing treatment.…”

Lost in Translation

“…[19][20]23 In this Patients seem to be more receptive to ICD deactivation discussions when they know they are nearing end-of-life. Lewis et al 6 completed a retrospective chart review of 63 patients, 20 with a terminal disease diagnosis and 43 without, to evaluate the strategy of discussing ICD deactivation with patients who developed a terminal illness. Identification of a terminal illness triggered a discussion regarding prognosis, end-of-life treatment preferences and the potential for device deactivation with the patient and family, and their physician care team.…”

“…As their condition worsens, patients with heart failure may develop hypoxia, sepsis, and electrolyte imbalances, which can serve to further potentiate arrhythmia, subsequently increasing shock frequency. 6 ICD shocks may in this setting become undesirable.…”

“…9 In an investigation comparing quality of life measures in ICD patients and those administered a pharmacological intervention, both physical and psychological functioning were diminished in the ICD group, especially in those who received >5 shocks. 6 Furthermore, the generally adverse and unpredictable timing of an ICD shock was found to be a source of psychological distress. 10 The number of years since implantation and number of ICD discharges were also positively correlated with anxiety, which occurs in 13% to 38% of patients.…”