Deactivation of Cardiac Devices at the End of Life: Clinical and Ethical Challenges

PURPOSE OF REVIEW: Device deactivation in patients with heart failure is an increasingly relevant clinical and ethical challenge as the use of cardiovascular implantable electronic devices expands. RECENT FINDINGS: Current guidelines affirm the ethical and legal permissibility of deactivating life-sustaining devices, including implantable cardioverter-defibrillators, pacemakers, and mechanical circulatory support systems, when requested by patients or surrogates with decision-making capacity. Importantly, guidelines from professional societies recommend that discussions about device deactivation be included in the pre-implantation consent process. However, clinical practice reveals persistent gaps in advance care planning, with device deactivation discussions remaining infrequent. Deactivating implantable cardioverter defibrillators can prevent painful and unnecessary shocks at the end of life, which may otherwise prolong dying without improving quality of life. Multidisciplinary involvement, including palliative care consultation, is essential to support patient-centered decision-making and symptom management. This review synthesizes the latest evidence and consensus on device deactivation in heart failure, emphasizing the need for communication, initiated early in the disease course, as well as individualized care, and integration of patient preferences throughout the disease trajectory.