Pacemaker Management in Hospice Patients
Introduction to Pacemaker Management
- The American College of Cardiology recommends that pacemakers should not be routinely removed or deactivated in hospice patients, as they do not prolong the dying process and cause no discomfort 1, 2
- The 2018 ACC/AHA/HRS guidelines state that pacemakers do not keep dying patients alive, as terminal events are typically caused by the underlying disease 1, 2, 3
Patient Rights and Counseling
- Patients have the absolute right to refuse or request withdrawal of any medical intervention, including pacemakers, according to the American College of Cardiology 1, 2, 4, 5, 6
- Honoring these requests is patient-centered care and ethically/legally permissible, as stated by the American College of Cardiology 1, 2, 4, 5, 6
- The American Heart Association and the Heart Rhythm Society emphasize the importance of discussing the consequences and alternatives of pacemaker deactivation with patients and their surrogates 1, 7, 3
Pacemaker Deactivation Procedures
- The American College of Cardiology mandates specific documentation for pacemaker deactivation, including a written physician order, accompanying DNR order, and confirmation of patient/surrogate request 1, 7, 3
- The American College of Cardiology also recommends documentation of patient capacity or identification of appropriate legal surrogate, as well as discussion of consequences and alternatives 1, 7, 3
Post-Deactivation Management
- The American College of Cardiology recommends monitoring closely for symptoms requiring intensification of comfort measures, particularly respiratory distress, after pacemaker deactivation 1, 7, 3
- The American College of Cardiology also suggests providing palliative care and medical support to patients and their families after pacemaker deactivation 1, 7, 3
Proactive End-of-Life Planning
- The American College of Cardiology recommends early conversations about device management, ideally beginning at the time of device implantation or early in terminal illness 7, 3
- The American College of Cardiology encourages patients to complete advance directives that specifically address device management 7, 4, 5, 6, 3