End-of-Life Management of Implantable Cardioverter-Defibrillators
Summary
Implantable cardioverter-defibrillators (ICDs) have transformed the prevention of sudden cardiac death by detecting and terminating malignant arrhythmias. As patients approach the end of life, however, the life-prolonging benefits of the device may become incongruent with individual goals of care. End-of-life management encompasses anticipatory discussions, technical deactivation of the shock function, decisions about generator replacement versus downgrade to a pacing-only system, and integration with palliative and hospice services. Ethical and legal frameworks support patients’ right to refuse or withdraw therapy, yet clinical practice often lags behind guidelines. Barriers to optimal management include clinician discomfort with deactivation conversations, fragmentation of care pathways and uncertainty about responsibility for advance care planning. Emerging strategies promote shared decision-making through structured trigger points, educational interventions for multidisciplinary teams and tailored communication tools. Globally, harmonising regulatory standards and fostering collaboration between cardiology, palliative care and primary care are essential to ensure that device management aligns with patients’ values and relieves unnecessary distress from inappropriate shocks at the terminal phase.
Research from Nature Portfolio
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End-of-Life Management of Implantable Cardioverter-Defibrillators publication trend
The graph below shows the total number of articles in end-of-life management of implantable cardioverter-defibrillators across all publications each year (not limited to Nature Index journals).
Technical terms
Implantable cardioverter-defibrillator (ICD): A surgically implanted device that monitors heart rhythm and delivers electrical therapy to correct life-threatening arrhythmias.
Deactivation: The intentional disabling of the ICD’s shock function to prevent further interventions in accordance with patient wishes.
Generator replacement: The surgical procedure to exchange the device battery and electronic unit when depleted; may involve continuation, downgrade or cessation of therapy.
Advance care planning: A process of discussion and documentation of future health preferences, including decisions about device deactivation.
Shared decision-making: A collaborative approach in which clinicians and patients jointly consider evidence, personal values and prognosis to reach a care plan.
References
- Implantable cardioverter defibrillator deactivation and advance care planning: a focus group study. Heart (2019).
- ‘You can’t start a car when there’s no petrol left’: a qualitative study of patient, family and clinician perspectives on implantable cardioverter defibrillator deactivation. BMJ Open (2021).
- Downgrade of cardiac defibrillator devices to pacemakers in elderly heart failure patients: clinical considerations and the importance of shared decision-making. Netherlands Heart Journal (2021).
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