title: End of life decisions in heart failure: to turn off the intracardiac device or not?
abstract: OBJECTIVE
  Heart failure is a significant public health concern around the world. Implantable cardioverter defibrillators with or without cardiac resynchronization therapy (CRT-D) have proven survival benefit. As patients progress to end-stage disease, management shifts to palliative care, and cardiologists are often confronted with how to best manage these devices.
  
  
  RESULTS
  Studies suggest that up to one-third of patients with an implantable cardioverter defibrillator receive painful shocks in the last 24 h of life. Disabling pacing or resynchronization devices may further weaken the heart function and expedite death, particularly if the patient has no underlying ventricular rhythm. Is it ethical or legal to discontinue functions of the implantable device? The discussion and the decision to be made are whether to continue both pacing and tachyarrhythmia therapies, disable tachyarrhythmia therapies while maintaining pacing, or discontinue both.
  
  
  CONCLUSIONS
  The decision to disable all or parts of the device function is ultimately up to the patient. To avoid painful shocks near the end of life, it is recommended that tachyarrhythmia therapies be turned off when the patient is being treated palliatively. After informed discussion, withdrawing the resynchronization or pacing device option is also acceptable if requested by the patient regardless of the potential outcomes.
authors.affiliation: Section of Cardiology, Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Bilal
authors.initials: B
authors.lastname: Ayach
authors.forename: Amrit
authors.initials: A
authors.lastname: Malik
authors.forename: Colette
authors.initials: C
authors.lastname: Seifer
authors.forename: Shelley
authors.initials: S
authors.lastname: Zieroth
mesh_terms: D001145:Arrhythmias, Cardiac; D058406:Cardiac Resynchronization Therapy; D003657:Decision Making; D017147:Defibrillators, Implantable; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D006801:Humans; D013727:Terminal Care; D016896:Treatment Outcome