Praxis Medical Insights

Est. 2024 • Clinical Guidelines Distilled

Made possible by volunteer editors from the University of Calgary & University of Alberta

Last Updated: 12/12/2025

ICD Deactivation in Hospice Patients

  • The American College of Cardiology, American Heart Association, and Heart Rhythm Society guidelines establish that deactivating ICDs in terminally ill patients is both ethical and legal, and is not considered physician-assisted suicide or euthanasia 1, 2, 3
  • Patients have the right to refuse or withdraw life-sustaining treatments, including ICDs, as established by the ACC/AHA/HRS guidelines 1, 2
  • Imposing device therapy on patients who do not want it is unethical and illegal, according to the ACC/AHA/HRS guidelines 1, 2

Clinical Rationale for Deactivation

  • Some patients experience uncomfortable defibrillations throughout the dying process, including moments before death, highlighting the need for proactive deactivation discussions 1, 2, 4
  • Patients and families fear that devices will prolong the dying process, emphasizing the importance of addressing these concerns through deactivation discussions 1, 2

Deactivation vs. Physical Removal

  • The American College of Cardiology recommends deactivating ICDs, not physically removing them, in hospice patients who request it, as part of end-of-life care planning 1, 5, 6
  • Deactivation can be accomplished immediately with a magnet or formally with a programmer, according to the ACC guidelines 1, 6

Required Process for Deactivation

  • The ACC/AHA/HRS guidelines mandate a structured approach to deactivation, including patient discussion and documentation, concurrent orders, consultation requirements, and conscientious objection 1, 2, 3
  • Device deactivation must be accompanied by a DNR order, and both orders must be recorded in the patient's medical record, as recommended by the ACC/AHA/HRS guidelines 1, 2, 3

Palliative Care Integration

  • Patients must receive comprehensive palliative measures to manage symptoms that may emerge from device deactivation, particularly if pacing therapy is withdrawn, according to the ACC guidelines 6

Critical Distinction: Pacemaker vs. ICD Function

  • Deactivating ICD shock function is clearly appropriate and causes no immediate physiologic change, whereas deactivating pacing in pacemaker-dependent patients will result in death, requiring more careful consideration, as noted by the ACC/AHA/HRS guidelines 1, 2

Proactive Discussion Requirement

  • The ACC/AHA guidelines recommend that patients with refractory end-stage heart failure and ICDs should receive information about the option to deactivate the defibrillator, ideally at device implantation 1, 5, 3
  • Patients should complete advance directives that specifically address device management, as recommended by the ACC/AHA guidelines 1, 3

Practical Implementation in Hospice Settings

  • The attending physician should contact the physician responsible for the device, and industry-employed allied professionals can bring a programmer to the bedside for deactivation, according to the ACC guidelines 6

Deactivating an Automated Implantable Cardioverter-Defibrillator (AICD) in a Dying Patient

Introduction to AICD Deactivation

  • The American Heart Association recommends that all facilities caring for patients with ICDs should have doughnut magnets on-site and readily available for emergency deactivation 7, 8
  • The American College of Cardiology suggests that patients have the same right to deactivate an ICD as any other life-sustaining therapy, both ethically and legally 7

Immediate Practical Steps for Deactivation

  • All ICDs can be deactivated by placing a doughnut magnet directly over the device, which disables the defibrillator function without requiring a programmer or technical expertise 7, 8, 9
  • The magnet should be left in place until magnet function is confirmed or a programmer is available, as devices differ in their response when the magnet is removed 7, 8, 9

Considerations for Patient Care

  • Twenty percent of patients receive shocks from their ICDs at the end of life, causing distress to both patients and families 7
  • Shocks have been described as causing significant pain, anxiety, and fear, which can decrease quality of life 7
  • The Heart Rhythm Society guidelines provide recommendations for discussing ICD shock deactivation in patients with refractory heart failure symptoms or nearing the end of life 10, 11, 12
  • Patients have the right to deactivate their ICD at any time if it is consistent with their goals and preferences 10, 11, 12
  • The American College of Cardiology and the Heart Rhythm Society recommend that clinicians should discuss ICD shock deactivation with patients who have refractory heart failure symptoms or are nearing the end of life 10, 11, 12

Palliative Care Integration for Deactivation

  • Establishing palliative care interventions and providing patient and family support before and after deactivation is essential 9
  • Patients must be offered the full range of palliative measures to treat symptoms associated with progression of their underlying illness 9

Common Pitfalls to Avoid in Deactivation

  • The most critical pitfall is delay, as dying patients may receive multiple painful shocks while waiting for formal deactivation procedures 7, 10, 11, 12
  • Understanding that magnet placement only deactivates the shock function, not pacing, is crucial for proper patient care 7, 9

REFERENCES

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