Pacemakers in palliative care

For general principles of planning deactivation of an implantable cardiac device, see General considerations when deactivating implantable cardiac devices in palliative care.

Pacemakers can have an active role in preventing symptoms and do not need to be turned off unless requested by the patient.

Many patients, families and carers are concerned that the pacemaker will prevent the patient from dying; however, provide reassurance that this is not true because the heart will no longer respond to the pacemaker output when death occurs. The effect of deactivating a pacemaker will depend on the underlying heart rhythm:

• If the underlying rhythm is normal, deactivating the pacemaker will have no or little effect.
• If the underlying rhythm is very slow, deactivating the pacemaker may cause light-headedness, breathlessness or loss of consciousness, but the patient will not die immediately.
• If there is no underlying rhythm, deactivating the pacemaker will usually cause death immediately; however, a slow ‘escape’ rhythm may develop some seconds later.

If deactivation of a pacemaker is considered, seek specialist advice from a member of the pacemaker follow-up team. Ensure the patient and their family are aware of the implications of deactivating a pacemaker. Planning to deactivate a pacemaker should mean that the timing of deactivation and the responses to symptoms can be anticipated and agreed on with patients and families.

If a pacemaker is going to be deactivated, a medical practitioner should be present to treat symptoms that may arise (eg breathlessness). If death is expected imminently, pre-emptive sedation and management of symptoms are needed. If death is likely to occur in the next few days, see Principles of care in the last days of life.