Approach to cardiac implantable electronic device management (permanent pacemakers and implantable cardioverter-defibrillators) in patients receiving palliative care*

CIED: cardiac implantable electronic device; ICD: implantable cardioverter-defibrillator; PPM: permanent pacemaker.
* There is no inherent code status among patients receiving palliative care. Patients may opt for a status of do not resuscitate (DNR), but may continue to choose active CIED therapies. Clarification of code status and the establishment of advanced directives, including CIED management, is an important component of the care plan.
¶ in patients without a health care proxy, decisions regarding capacity may require evaluation by psychiatric experts, legal review for determining guardianship, etc.
Δ In general, CIED reprogramming occurs in a controlled setting on an elective basis. The one exception may be for a patient who is receiving repetitive ICD shocks in whom placing a magnet over the ICD will terminate the delivery of shocks.
◊ On occasion, the clinician who is asked to withdraw pacemaker therapy in a pacemaker-dependent patient may disagree with the decision to withdraw pacemaker therapy or may have a conscientious objection to performing this. In this situation, the patient should be referred for another opinion by a clinician with expertise in pacemakers, or a consultation with the hospital ethics committee may be requested.
§ Expected clinical course will vary based on type of CIED. In most cases, deactivation of an ICD or a PPM in a non-pacemaker dependent patient will not immediately impact the patient's clinical condition. Deactivating a PPM in a patient who is pacemaker dependent may lead to an immediate deterioration of clinical condition and/or fairly rapid demise depending upon the patient's underlying cardiac rhythm and overall hemodynamic status.