All we are doing by deactivating shocks is complying with a patient’s wishes. Consider that most terminal patients request to be DNR (do not resuscitate) or AND (allow natural death). The critical point here is that deactivating shocks on an ICD has no immediate effect for the patient. What’s more, and this is too often forgotten, a shock for sudden cardiac arrest prevents the kind of death most people hope for–a painless, quick and peaceful death. This is because shocks are painful and often anxiety provoking. When a patient with an ICD approaches end of life, it is appropriate to deactivate shocks. This differs from a pacemaker, which is used only to treat slow heart rates. Recall that an ICD serves two main functions: 1) it senses then treats dangerously fast rhythms with either painless overdrive pacing or (not painless) high-voltage shocks, and 2) all ICDs come with built-in pacing capability for slow heart rhythms. In the real world, the overwhelming majority of requests for deactivation (my guess is 999/1000) are to turn off ICD shocks. There are many important differences I will discuss the ones pertaining to deactivation later. The first two questions to clarify are: What is a cardiac device and what does it mean to deactivate it? When we say “cardiac device” we are referring to either an Internal Cardiac Defibrillator (ICD) or a pacemaker. Her coverage came about because of this Mayo Clinic paper published in JAMA-IM, which showed most patients with cardiac devices approach end of life without proper preparation. As I wrote yesterday, Paula Span of the NY Times covered this important issue earlier this week. The purpose of this post is to clarify important issues about cardiac devices as they relate to deactivation.
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