A 79-year-old with end-stage heart failure and an implantable cardioverter defibrillator is receiving repeated shocks in his final days. His wife asks you to 'turn it off'. How do you approach this?

Question

A 79-year-old man with ischaemic cardiomyopathy, EF 15%, NYHA IV, is admitted with decompensated heart failure that has not responded to intravenous diuretics. He is on a palliative care pathway with a DNACPR in place. Overnight he received four ICD shocks for ventricular arrhythmia and is distressed and frightened. His wife asks whether the device can be switched off.

Accepted Answer

This is a distressing and entirely addressable harm, and I would treat it urgently. Repeated shocks in a dying patient cause pain and fear and confer no benefit, so deactivating the defibrillation therapy is the withdrawal of a treatment that is no longer of benefit. That is lawful and is ethically and legally distinct from assisted dying, and I would say that plainly to his wife because families often fear they are being asked to end his life. My first step would be to assess whether he has capacity for this decision. If he does, the conversation is with him, and his wife is there to support rather than to decide. If he does not, I would act in his best interests under the Mental Capacity Act, consulting his wife about his previously expressed wishes and checking for an advance decision or ReSPECT form. Practically, I would contact the cardiac physiology service to reprogramme the device. Out of hours, or if he is being shocked repeatedly now, a ring magnet placed over the device suspends shock therapy immediately, and I would arrange that while the physiologist is being contacted. I would explain that the pacing function is retained, so he will not deteriorate suddenly because of this — that is usually the reassurance the family needs most. Alongside this I would optimise symptom control with palliative care input, address the arrhythmia burden with antiarrhythmic therapy if appropriate, document the decision and the discussion fully, and make sure the GP, community palliative team and device clinic are all informed.

Deactivating an ICD at the End of Life

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