Dying with/despite a pacemaker

Death of intensive care unit (ICU) patients with cardiovascular implantable electronic devices (CIED) is a common scenario in the ICU. Given the demographic trends and the increasing implantation rate of such devices reinforces the fact that ICU physicians must be aware of the burden and consequences of these systems in the end of life care of dying patients. The possible deactivation of a CIED confronts the responsible physicians with particularly complex clinical, ethical, and legal problems. Most deaths are often preceded by a long illness trajectory and finally by altering the therapeutic goals. Withholding or withdrawing therapy are the results of these processes. General agreement exists that ICD deactivation in dying patients may be ethically permissible. The patient's consent is mandatory. The practices and attitudes associated with pacemaker deactivation differ significantly from those associated with ICD deactivation. It is therefore crucial to be aware of the legal situation in the jurisdiction in which the physician is practicing. The decision to deactivate CIEDs should be part of a well deliberated and transparent process. Ethical and legal guidance should be readily available to counsel and support these difficult decisions.