Recommended Citation
Grannan H, Badi N, Sharma K. A Heart-Stopping Decision: An Ethical Dilemma Involving Pacemaker Deactivation at End of Life. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Introduction/Background:
Pacemaker deactivation at the end of life presents complex ethical and logistical challenges. While Heart Rhythm Society affirms a patient’s right to withdraw life-sustaining treatments, clinicians often experience moral distress when patients are pacemaker-dependent. Unlike defibrillators, pacemakers are perceived as integral to the body rather than external interventions, leading to concerns regarding hastening of death with pacemaker deactivation. In this case, we highlight how device manufacturer procedural requirements can also create obstacles to deactivation, resulting in unintended prolonged suffering and increased distress for the patient and family.
Description:
A 74-year-old male with metastatic renal cell carcinoma developed third-degree heart block, necessitating a permanent pacemaker. Over the subsequent four weeks, the patient experienced progressive functional decline, becoming unable to participate in rehabilitation. Due to poor quality of life with profound dysphagia, anorexia, pain, and dyspnea—the patient requested deactivation of the device to align with comfort-focused goals. While the hospital ethics committee confirmed the patient’s capacity and affirmed that deactivation was ethically equivalent to withdrawing other life-sustaining treatments, the treating cardiologists declined to perform the procedure based on personal ethical objections. The patient was transferred to hospice care, where such device deactivation had been performed within the preceding 12 months. Upon transfer, however, the device manufacturer declined to provide programming support, citing changes in liability policy. The patient died eight hours later with the device still functioning, resulting in significant distress to the family.
Discussion:
Ethical principles of autonomy, beneficence, justice, and non-maleficence were all at play in this case. We identified a need to create a protocol to address requests for pacemaker deactivation. Following this case, an interdisciplinary framework involving cardiology, ethics, risk management, and palliative care was established. This provides clear clinical pathways for deactivation, identifies "willing providers" to ensure timely access, and includes pre-negotiated agreements with manufacturers for technical support. This can be formalized into an institutional policy for future requests and provide a scalable model for ensuring patient-centered end-of-life care across the health system.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Poster
Open Access
Available to all.
A Heart-Stopping Decision: An Ethical Dilemma Involving Pacemaker Deactivation at End of Life
Introduction/Background:
Pacemaker deactivation at the end of life presents complex ethical and logistical challenges. While Heart Rhythm Society affirms a patient’s right to withdraw life-sustaining treatments, clinicians often experience moral distress when patients are pacemaker-dependent. Unlike defibrillators, pacemakers are perceived as integral to the body rather than external interventions, leading to concerns regarding hastening of death with pacemaker deactivation. In this case, we highlight how device manufacturer procedural requirements can also create obstacles to deactivation, resulting in unintended prolonged suffering and increased distress for the patient and family.
Description:
A 74-year-old male with metastatic renal cell carcinoma developed third-degree heart block, necessitating a permanent pacemaker. Over the subsequent four weeks, the patient experienced progressive functional decline, becoming unable to participate in rehabilitation. Due to poor quality of life with profound dysphagia, anorexia, pain, and dyspnea—the patient requested deactivation of the device to align with comfort-focused goals. While the hospital ethics committee confirmed the patient’s capacity and affirmed that deactivation was ethically equivalent to withdrawing other life-sustaining treatments, the treating cardiologists declined to perform the procedure based on personal ethical objections. The patient was transferred to hospice care, where such device deactivation had been performed within the preceding 12 months. Upon transfer, however, the device manufacturer declined to provide programming support, citing changes in liability policy. The patient died eight hours later with the device still functioning, resulting in significant distress to the family.
Discussion:
Ethical principles of autonomy, beneficence, justice, and non-maleficence were all at play in this case. We identified a need to create a protocol to address requests for pacemaker deactivation. Following this case, an interdisciplinary framework involving cardiology, ethics, risk management, and palliative care was established. This provides clear clinical pathways for deactivation, identifies "willing providers" to ensure timely access, and includes pre-negotiated agreements with manufacturers for technical support. This can be formalized into an institutional policy for future requests and provide a scalable model for ensuring patient-centered end-of-life care across the health system.
Affiliations
Aurora St. Luke’s Medical Center, Aurora Sinai Medical Center, Aurora Zilber Family Hospice