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

Abstract

The recently published 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities1 include a discussion of ethical issues surrounding the deactivation of pacemakers, implanted cardioverter-defibrillator (ICDs), and CRT devices in patients who are terminally ill. The authors rightly note that most clinicians make an ethical distinction between deactivating an ICD and deactivating a permanent pacemaker. Programming an ICD so that it will not provide antitachycardia therapy in the event of ventricular tachycardia or ventricular fibrillation in a terminally ill patient who requests this action seems to be widely accepted as morally permissible.2–8 Many patients and physicians find the deactivation of an ICD in this situation as morally equivalent to a “do not resuscitate” order. Deactivation of an ICD in a patient who is dying of a terminal illness, whether cardiac or another condition, prevents the delivery of painful ICD shocks and allows the patient to die of the natural progression of their underlying disease. As such, this action seems a humane withdrawal of a futile medical treatment. Response by Zellner et al on p 336 In contrast to deactivating an ICD in a dying patient, there is more controversy regarding whether a pacemaker can be deactivated at the request of a terminally ill patient, especially if the patient is pacemaker dependent. Although some authors have suggested that it may be morally permissible to discontinue pacing therapy in patients who are hopelessly ill and request this action,5 we believe that there can be a fundamental difference between discontinuation of antitachycardia and antibradycardia therapies in some patients, depending on their degree of pacemaker dependency. For example, consider a patient with complete heart block who has long had a permanent pacemaker implanted. Pacing by itself does not prevent the patient from following the natural course of their disease and does …