General considerations when deactivating implantable cardiac devices in palliative care

Implantable cardiac devices include cardiac implantable electronic devices (CIEDs) and ventricular assist devices.

Cardiac implantable electronic devices include:

• pacemakers—these devices pace the heart and maintain a cardiac rhythm
• implantable cardioverter defibrillators (ICDs)—these devices have the same pacing functions as pacemakers. In addition, they can:
  • deliver fast pacing to overdrive ventricular tachycardia (anti-tachycardia pacing)
  • deliver a shock to cardiovert ventricular tachycardia or defibrillate ventricular fibrillation.

Without a pacemaker or an ICD, patients may have no rhythm, have a slow heart rate, or have a normal heart rhythm so that they only need pacing intermittently.

A ventricular assist device augments cardiac output.

Patients with palliative care needs may have an implantable cardiac device that contributes to symptom management. Decisions to deactivate devices can be complex and distressing. Any plan for deactivation of an implantable cardiac device needs to be discussed with patients and their family and carers. Discussions should include whether and when the device is deactivated, and the consequences and impact of deactivation. For general advice on decision-making around withdrawing or withholding treatment, see Decisions about withdrawing or withholding treatment in palliative care. The patient’s cardiologist is best placed to start the conversation about device deactivation (ideally before implantation), but other healthcare professionals (eg general practitioners, geriatricians, palliative care specialists) may need to discuss the process. The decision-making process should involve the patient’s healthcare team (including palliative care specialists, if involved) to enhance clarity and support.

For implications of deactivating an implantable cardiac device, see the following device-specific information:

• ICDs
• pacemakers
• ventricular assist devices.

If deactivation of a device is to be performed by a nonmedical person, there should be a clear written directive from a doctor.

Implantable cardiac devices will need to be removed after death if the body is to be cremated. For general guidance on legal requirements after a patient has died, including additional considerations if the body is to be cremated, see Legal requirements after a patient has died.