End-of-Life Issues: Management of Cardiac Implantable Electronic Devices

  • Cynthiane J. MorgenweckEmail author


It has become increasingly acceptable for clinicians to disable cardiac devices placed in a patient if the patient so requests. When deactivation was first proposed, there was significant resistance. However, with the rise of patient autonomy, the recognition that quality of life is a patient judgment and the increased burdens of multiple chronic illnesses patients face as they live longer, device deactivation is a reasonable approach in end-of-life care. The three intracardiac devices (pacemaker, automatic implantable cardioverter defibrillator and ventricular assist device) have different benefits, burdens and deactivation trajectories. This chapter will review the commonalities and differences and suggest some talking points when there is a request for deactivation.


End-of-Life Ethics Deactivation Pacemakers Automatic Implantable Cardioverter Defibrillators Ventricular Assist Devices 


  1. 1.
    Lampert R, Hayes DL, Annas GJ, Farley MA, Goldstein NE, Hamilton RM, et al. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm. 2010;7(7):1008–26.CrossRefPubMedGoogle Scholar
  2. 2.
    Allen LA, Stevenson LW, Grady KL, Goldstein NF, Matlock DD, Arnold RM, et al. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2012;125(5):1928–52.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Mueller PS, Swetz KM, Freeman MR, Carter KA, Crowley ME, Severson CJ, Park SJ, Sulmasy DP. Ethical analysis of withdrawing ventricular assist device support. Mayo Clin Proc. 2010;85(9):791–7.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Huddle TS, Bailey FA. Pacemaker deactivation: withdrawal of support or active ending of life. Theor Med Bioeth. 2012;33(6):421–33.CrossRefPubMedGoogle Scholar
  5. 5.
    Kinzbrunner BM. Jewish medical ethics and end-of-life. J Palliat Med. 2004;7(4):558–73.CrossRefPubMedGoogle Scholar
  6. 6.
    Miller FG, Truog RD, Brock DW. Moral fictions and medical ethics. Bioethics. 2010;24(9):453–60.CrossRefPubMedGoogle Scholar
  7. 7.
    Butler K. Knocking on heaven’s door: the path to a better way of death. New York: Scribner; 2014. p. 1–3.Google Scholar
  8. 8.
    Rhymes JA, McCullough LB, Luchi RJ, Teasdale TA, Wilson N. Withdrawing very low-burden interventions in chronically ill patients. JAMA. 2000;283(8):1061–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Pelligrino ED. Decision to withdraw life-sustaining treatment. JAMA. 2000;283(8):1065–7.CrossRefGoogle Scholar
  10. 10.
    Whitlock SN, Goldberg IP, Singh JP. Is pacemaker deactivation at the end of life unique?: a case study and ethical analysis. J Palliat Med. 2011;14(10):1184–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Mueller PS, Hook C, Hayes DL. Ethical analysis of withdrawal of pacemaker or implantable cardio-defibrillator support at the end of life. Mayo Clin Proc. 2003;78(8):959–63.CrossRefPubMedGoogle Scholar
  12. 12.
    Jauhar S. Jolts of anxiety. New York Times. 5 May 2002.Google Scholar
  13. 13.
    Kohn CS, Petrucci RJ, Baessler C, Soto DM, Mosowitz C. The effects of psychological intervention on patient’s long-term adjustments to the ICD: a prospective study. PACE. 2000;23(4):450–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Paola FA, Walker RM. Deactivating the implantable cardioverter-defibrillator: a biofixture analysis. South Med J. 2000;93(1):20–3.CrossRefPubMedGoogle Scholar
  15. 15.
    Sulmasy DP. Within you/without you: biotechnology, ontology and ethics. J Gen Intern Med. 2008;23(S1):69–72.CrossRefPubMedGoogle Scholar
  16. 16.
    Matlock DD, Stevenson LW. Life-saving devices reach the end of life with heart failure. Prog Cardiovasc Dis. 2012;55(3):274–81.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Hauptman PJ, Havranek EP. Integrating palliative care into heart failure care. Arch Int Med. 2005;165(4):374–8.CrossRefGoogle Scholar
  18. 18.
    Yuan N, Arnaoutakis GJ, Georg TJ, Allen JG, Ju DG, Schaffer JM, et al. The spectrum of complications following left ventricular assist device placement. J Card Surg. 2012;27(5):630–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Brush S, Budge D, Alharethi R, McCormick AJ, MacPherson JE, Reid BB, et al. End-of-life decision making and implementation in recipients of a destination left ventricular assist device. J Heart Lung Transplant. 2010;29(12):1337–41.CrossRefPubMedGoogle Scholar
  20. 20.
    Bruce C. A review of ethical considerations for ventricular assist device placement in older adults. Aging Dis. 2013;4(2):100–12.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Swetz KM, Freeman MR, AbouEzzeddine OF, Carter KA, Boilson BA, Ottenberg AL, et al. Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist devices as destination therapy. Mayo Clin Proc. 2011;86(6):493–500.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Hupcey JE, Penrod J, Fenstermacher K. A model of palliative care for heart failure. Am J Hosp Palliat Med. 2009;26(5):399–404.CrossRefGoogle Scholar
  23. 23.
    Quaglietti S, Pham M, Froelicher V. A palliative care approach to the advanced heart failure patient. Curr Card Rev. 2005;1(1):45–52.CrossRefGoogle Scholar
  24. 24.
    Butler K, Puri S. Deathbed shock: causes and cures. JAMA Int Med. 2014;174(1):88–9.CrossRefGoogle Scholar
  25. 25.
    Pasalic D, Tajouri TH, Ottenberg AL, Mueller PS. The prevalence and contents of advance directives in patients with pacemakers. PACE. 2014;37(4):473–80.CrossRefPubMedGoogle Scholar
  26. 26.
    Tajouri TH, Ottenberg AL, Hayes DL, Mueller PS. The use of advance directives among patients with implantable cardiac defibrillators. PACE. 2012;35(5):567–73.CrossRefPubMedGoogle Scholar
  27. 27.
    Fromme EK, Stewart TL, Jeppesen M, Tolle SW. Adverse experiences with implantable defibrillators in Oregon hospices. Am J Hosp Palliat Med. 2011;28(5):304–9.CrossRefGoogle Scholar
  28. 28.
    Mueller PS, Ottenberg AL, Hayes DL, Koenig BA. “I felt like the angel of death”: role conflicts and moral distress among allied professionals employed by the US cardiovascular implantable electronic device industry. J Interv Card Electrophysiol. 2011;32(3):253–61.CrossRefPubMedGoogle Scholar
  29. 29.
    Bevins MB. The ethics of pacemaker deactivation in terminally ill patients. J Pain Symp Manage. 2011;41(6):1106–10.CrossRefGoogle Scholar
  30. 30.
    Buchhalter LC, Al O, Webster TL, Swetz KM, Hayes DL, Mueller PS. Features and outcomes of patients who underwent cardiac device deactivation. JAMA Intern Med. 2014;174(1):80–5.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Jacob S, Panaich SS, Maheshwari R, Haddad JW, Padanilam BJ, John SK. Clinical applications of magnets on cardiac rhythm devices. Europace. 2011;13(9):1222–30.CrossRefPubMedGoogle Scholar
  32. 32.
    Kramer DB, Ottenberg AL, Gerhardson S, Mueller KA, Kaufman SR, Koenig BA, Mueller PS. “Just because we can doesn’t mean we should”: views of nurses on deactivation of pacemakers and implantable cardio-defibrillators. J Inter Card Electrophysiol. 2011;32(3):243–52.CrossRefGoogle Scholar
  33. 33.
    Stolberg SG. On medicine’s frontier: the last journey of James Quinn. The New York Times. 8 Oct 2002.Google Scholar
  34. 34.
    Jolly D. Recipient of artificial heart goes home. The New York Times. 9 Jan 2015.Google Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Center for Bioethics and Medical HumanitiesMedical College of WisconsinMilwaukeeUSA

Personalised recommendations