Cardiac pacemakers and implantable defibrillators in terminal care

The use of cardiac cardiac pacemakers and arrhythmia control devices is inc reasingly common. The presence of a previously placed pacemaker or implanta ble cardioverter-defibrillator (ICD) in a terminally ill patient may result in medical and ethical issues for the patient, family and healthcare provi der. Two cases am presented to illustrate the complex issues that may wise in the terminally ill with a pacemaker or an ICD. Based on these cases and a review of published data, it is likely that the disabling of a previously placed pacemaker will neither hasten nor prolong the natural history elf t he underlying illness in most instances. There are uncommon but potentially severe adverse effects of disabling the pacemaker; therefore, pacemakers s hould generally be left intact in terminally ill patients. It is mom diffic ult to generalize as to whether deactivation of an ICD is appropriate; in t his case death may be hastened and the decision concerning an ICD will depe nd on the specific clinical scenario. Patient and family education regardin g palliative care treatment goals and the function of pacemakers and other implanted arrhythmia control devices can help to alleviate anxiety surround ing the impact of this technology at the end of life (C) U.S. Cancer Pain R elief Committee, 1999.