M. MOTAZ BAIBARS, MD Department of Hospital Medicine, Peninsula Regional Medical Center, Salisbury, MD Yes. Although implantable cardio- verter-deibrillators (ICDs) prevent sudden cardiac death in patients with ad- vanced heart failure, their beneit in termi- nally ill patients is small. 1 Furthermore, the shocks they deliver at the end of life can cause distress. Therefore, it is reasonable to consid- er ICD deactivation if the patient or family wishes. See related commentary, page 99 ■ A DIFFICULT DECISION End-of-life decisions place signiicant emo- tional burdens on patients, their families, and their healthcare providers and can have social and legal consequences. Turning off an ICD is an especially difi- cult decision, considering that these devices protect against sudden cardiac death and fatal arrhythmias. Also, patients and their repre- sentatives may ind it more dificult to with- draw from active care than to forgo further interventions (more on this below), and they may misunderstand discussions about ICD de- activation, perceiving them as the beginning of abandonment. ■ ICD DEACTIVATION IS OFTEN DONE HAPHAZARDLY OR NOT AT ALL Many healthcare providers are not trained in or comfortable with discussing end-of-life issues, and many hospitals and hospice pro- grams lack policies and protocols for manag- ing implanted devices at the end of life. Con- sequently, ICD management at the end of life varies among providers and tends to be sub- optimal. 2 In a report of a survey in 414 hospice fa- cilities, 97% of facilities reported that they ad- mitted patients with ICDs, but only 10% had a policy on device deactivation. 3 In a survey of 47 European medical cen- ters, only 4% said they addressed ICD deacti- vation with their patients. 4 A study of 125 patients with ICDs who had died found that 52% had do-not-resusci- tate orders. Nevertheless, in 100 patients the ICD had remained active in the last 24 hours of their life, and 31 of these patients had re- ceived shocks during their last 24 hours. 5 In a survey of next of kin of patients with ICDs who had died of any cause, 6 in only 27 of 100 cases had the clinician discussed ICD deactivation, and about three-fourths of these discussions had occurred during the last few days of life. Twenty-seven patients had re- ceived ICD discharges in the last month of life, and 8% had received a discharge during the inal minutes. ■ TRAINING AND PROTOCOLS ARE NEEDED Healthcare professionals need education about device deactivation at the end of life so that they are comfortable communicating with patients and families about this critical issue. To this end, several cardiac and pallia- tive care societies have jointly released an ex- pert statement on managing ICDs and other implantable devices in end-of-life situations. 7 Many providers harbor a misunderstand- ing of the difference between withholding a de- vice and withdrawing (or turning off) a device that is already implanted. 2 Some mistakenly believe they would be committing a crime by deactivating an implanted life-sustaining device. Legally and ethically, there is no dif- ference between withholding a device and CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 83 • NUMBER 2 FEBRUARY 2016 97 1-MINUTE CONSULT doi:10.3949/ccjm.83a.15007 BRIEF ANSWERS TO SPECIFIC CLINICAL QUESTIONS It is reasonable to consider ICD deactivation near the end of life if the patient or family so wishes Q: Can patients opt to turn off implantable cardioverter-defibrillators near the end of life? M. CHADI ALRAIES, MD, FACP Department of Medicine, Cardiovascular Division, University of Minnesota, Minneapolis AMJAD KABACH, MD Department of Medicine, Creighton University, Omaha, NE MARC PRITZKER, MD, FACC Professor of Medicine, Surgery and Biomedical Innovation; Director, Pulmonary Hypertension Service, University of Minnesota, Minneapolis A: