Guideline for Implantable - Local Referral and Management ...

Guideline for Implantable Cardioverter
Defibrillator (ICD) Deactivation

What is an ICD?

An ICD is an implanted device used to treat ventricular tachycardia (VT) and ventricular fibrillation (VF), by
continual monitoring of the heart rhythm and delivering anti-tachycardia pacing or a defibrillation shock
when it detects VF/VT. ICD’s also provide pacing support in the event of bradycardia.

An ICD may also have a biventricular pacemaker function for the management of heart failure (Cardiac
Resynchronisation Therapy – CRT-D). This part of the device is not switched off.

Why deactivate an ICD?

At the end of life and after death, there is a risk of the device delivering a shock which is painful and
traumatic to the patient and can be distressing for those present.

When should deactivating the ICD be discussed?

 Last minute discussions should be avoided as there may not be the facility to provide deactivation
out of hours. Deactivation issues should be discussed prior to implant as part of the informed
consent process.

 Health care professionals have a duty to discuss the risks and benefits of device therapy in the
context of the patient’s current illness trajectory.

 While the patient is still able to be involved in the decision making process and should include the
next of kin or close family.

If a patient lacks capacity to make the decision local/trust policy should be
followed

Deactivating an Implantable Cardioverter Defibrillator (ICD) means ‘turning off’ the shocking function of
the defibrillator so that a patient is not unnecessarily ‘shocked’ in the last minutes of life. The ICD will
continue to provide bradycardia (slow heart rhythm) support should the patient need it but will no longer
provide lifesaving therapy in the event of a ventricular tachyarrhythmia. Turning off the ICD will not cause
death.

When a patient is nearing the end of their life, it is usually recommended that any implanted device is
deactivated. The British Heart Foundation guidelines (2009, p. 8) recommends:

“Health professionals working with dying patients should be made aware of the increasing numbers of
Patients who have an ICD implanted, particularly for the treatment of heart failure.”

“Health professional have responsibility to ensure that the function of the ICD is optimised in the best
interests of the patients, particularly for those close to the point of death.

What needs to be discussed with patient/relatives prior to ICD deactivation?

 Turning off the ICD will NOT cause death. Bradycardia support will still be provided by the device
but life saving therapy for a ventricular tachyarrhythmia will be deactivated.

 ICD deactivation is not painful, nor will its failure to function cause pain. It is similar to a regular
pacing/cardiac clinic follow up check.

 Discuss who the named professional will be to lead the patients care from this point onwards,
deactivation decisions can be reversed.

Who can request ICD deactivation?

 The patient
 Palliative care physician/nurse
 Medical team in charge of patient when admitted
 GP
 Cardiac physiologist/ Heart failure or Arrhythmia nurse specialist

This must be discussed with the patient and their family/NOK as consent is required. This is to ensure
patients and their families can make informed timely decisions and should ideally be in consultation with the
cardiologist/arrhythmia & device nurse/cardiac physiologist:

Process for ICD deactivation;

Follow the deactivation algorithm which includes guidance for planned and emergency
situations.

 Prior discussion should have taken place with the appropriate Health Professionals
 Completion of ‘Request for Deactivation’ form. (found at the end of this document)
 A Cardiac physiologist will visit the patient (if an I/P) or make an appointment in the pacing clinic to

perform the deactivation. A health care professional involved in the patients care should be present
at deactivation.
 This is a simple non-invasive procedure and takes only a few minutes
 On completion the form (appendix 1) should be copied and filed appropriately (see algorithm)

Emergency temporary ICD deactivation using a magnet

Emergency ICD deactivation can be done by placing a magnet directly over the implant site. This stops the
ICD delivering any shock or ATP therapy but does not disable bradycardia pacing delivery. This is a
temporary solution as the ICD will return to normal function as soon as the magnet is removed. The ICD will
still require deactivation by a cardiac physiologist using a programmer after death. This deactivation
method may be considered if a planned ICD deactivation was not arranged and a cardiac
physiologist cannot get to the patient in time. Magnets are available out of hours via CCU. (see contact
page)

IMPORTANT

The process of deactivation is fully reversible if the patient recovers sufficiently from a
worsening condition

It is particularly important that the ICD is deactivated following the death of a patient and
before removal of the device prior to cremation

Who to Contact - Cardiac Investigations Unit 01243 831585
CCU (01243) 831570 for the on call registrar
St Richards Hospital
Monday- Friday 8.30-5.00
Out of Hours

Worthing Hospital

Monday-Friday 9.00-5.00 Pacing Clinic 01903 205111 ext 85860
Cardiac Department 01903 205111 ext 85631

Out of Hours CCU (01903) 205111ext 85630

Further Contacts:

St Richards Hospital; Clare Tate Arrhythmia and Devices Nurse Specialist
01243 788122 ext 5160

Worthing Hospital; Sarah Unsted Arrhythmia and Devices Nurse Specialist
01903 205111 ext 85757 Bleep 805

References:
Arrhythmia Alliance (2005, revised 2013). “Deactivating ICD shocks” in ICD/S-ICD
patient information, p. 19
http://heartrhythmcharity.org.uk/www/204/0/ICDS-ICD/

British Heart Foundation (2007). Implantable cardioverter defibrillators in patients who are
reaching the end of life: a discussion document for health professionals
http://www.bcs.com/documents/ICS_in_patients_who_are_reaching_the_end_of_life.pdf

Surrey Cardiac Physiologists Network and South London Cardiovascular and Stroke Network
(2013). Guidelines for deactivating implanatable cardioverter defibrillators (ICDs) in people nearing
the end of life.
http://www.slcsn.nhs.uk/files/cardiac/sl-guidelines-icd-deactivation-012013.pdf

Authors: Sarah Unsted & Clare Tate, Arrhythmia and Devices Nurse Specialists, Original
document authors: Lorraine Willis, Senior Chief Cardio Physiologist, Dr Colin Reid, consultant
cardiologist SRH, Dr Barry Kneale, consultant cardiologist WASH, WSHfT.
Others involved: Dr Mark Tanner, consultant cardiologist, WSHfT

Date Published: January 2010 Reviewed: 03/12, 03/14, 02/15
Review Date: February 2017

ICD Deactivation Algorithm

Discuss ICD deactivation early when patient approaching end of life as appropriate,
ideally in consultation with the Cardiologist and Arrhythmia/Device Nurse
Specialist/Cardiac physiologist

 When resuscitation issues are explored or a DNR order is in place.
 When a patient’s condition is worsening despite optimal therapy
 When a patient has co-morbidities with poor prognosis e.g. malignancy/advanced renal

disease.
 When transfer to a hospice or home for end of life care is being planned
 When referral to palliative care team is being considered
 When a Patient Advance Directive is in place.

Planned Emergency

Obtain ICD ID card from patient with For use when death is imminent
details/model/implanting centre and a planned deactivation has

(contact local cardiac/ pacing clinic if not taken place
information unavailable)
Place magnet over device usually
Contact cardiac clinic/pacing clinic to left side of chest below clavicle,
discuss and arrange deactivation with (NB right sided implants do exist)

Cardiac physiologist and secure with tape

Complete ‘request for deactivation’ Please note magnet is only
form, gain consent and document in effective when in position.
Leave magnet on even after
medical notes
death.
Patient attends hospital for scheduled
ICD deactivation as an outpatient.
If an inpatient, arrange ward visit by
cardiac physiologist.

Patient Death
Inform funeral home/mortuary

that patient has an ICD

Request for Deactivation of Implanted Cardiovertor Defibrillator

(ICD/CRT-D)

Patient Name: ………………………………………………………………………………….. Device Details (patient should have
Hospital number: …………………………………………………………………………….. an ID card with this information)
NHS Number : ……………………………………………………………………………………
Manufacturer: and/or
Implant Hospital:

Date of Birth: ……………………………………….

Normal Address: ……………………………………………………………………………………………………………………………………………………………………….

Address/Ward patient is currently located (if different to above): …………………………………………………………………………………

GP Name: ………………………………………………………………. GP Practice: ……………………………………………………………………………

GP Tel: ………………………………………………………………………….. GP Fax: ……………………………………………………………………………………

Authorisation

I understand the reasons for de-activating my ICD and that the decision to de-activate can be reviewed
if necessary. I agree to the deactivation of my ICD.

Signature of patient: ……………………………………………… Date: ………………………………………

Or if not the patient please complete the box below:

I understand the reasons for the de-activating the ICD of the patient named above and that the
decision to de-activate can be reviewed if necessary. I agree with the decision to deactivate the ICD.

Signature of next of kin: ………………………………………………… Relationship to patient: …………………………………………………

Print name: ……………………………………….................. Date: ……………………………………….

Deactivation
Date of request: …………………………………..…. (dd/mm/yyyy) Time of request: ………………………………………………….(hh:mm)

Reason for request: …………………………………………………………………………………………………………………………………………………………….

Signature of authorising clinician: .................................................... Print Name: ………………………………………………………..….

Signature of Cardiac physiologist
de-activating the device: ……………………………………………………….……… Print Name : ……………………………………….…………………

Date and time device de-activated: …………………………… (dd/mm/yyyy) …………………………. (hh:mm)
The completed form must be returned to the cardiac dept. A copy will be filled in the
patient’s hospital notes and a copy faxed to their GP and palliative care (if appropriate)