Pacemaker Deactivation vs. Removal for a 90-Year-Old with Advanced Dementia and Poor Quality of Life?
When a loved one with a pacemaker approaches the end of life, families may worry that the device will prevent a natural death. Learn what pacemakers can and cannot do, how they differ from ICDs, and what to consider before replacing or deactivating a cardiac device.
This article explains pacemakers and end-of-life care, including the natural dying process, pacemaker dependency, ICD deactivation, generator replacement, advance directives, hospice care, and questions families should ask the healthcare team.
My wife has a pacemaker. She will be 90 yrs. In dec.. the family is considering having it removed .reasons she has dmensure, sleeps 19hrs Aday , can hardly walk withe walker, has spinel stnousous, has very poor vision inright eye due to strock has minor vision in left eye due lazy at birth, has urinary track infections regully ,has major inconstinance. She continually begs for god to take her. Her quality of life is very poor. The yuro’s
-John
John,
This is a difficult decision, and it may help to understand what a pacemaker can—and cannot—do as a person approaches the end of life.
When the body begins the natural dying process, its systems gradually slow down. She may sleep more, become less responsive, lose interest in food and fluids, produce less urine, and develop cooler or mottled hands and feet as circulation decreases. Her breathing may become irregular, with shallow breaths or pauses. These changes are generally caused by the underlying illness and the body’s organs gradually losing their ability to function.
A pacemaker monitors the heart’s electrical activity and sends a small electrical impulse when the heartbeat becomes too slow. It can help regulate the heart’s rhythm, but it cannot make a failing heart pump effectively, prevent the other organs from shutting down, or reverse the underlying illness. If she begins actively dying, the pacemaker usually will not stop that natural process.
It is also important to confirm whether she has a pacemaker alone or a device that includes an implantable cardioverter-defibrillator, commonly called an ICD. An ICD can deliver shocks to correct a dangerous heart rhythm. Those shocks can be painful and distressing near the end of life, so families are often asked whether they want the ICD’s shock function turned off. Turning off the shock function does not necessarily turn off the pacemaker function.
A pacemaker is not automatically turned off when someone enters hospice or begins dying. Pacemaker deactivation is an individualized decision, particularly when a person is completely dependent upon the pacemaker. The cardiologist should explain what would likely happen if it were deactivated. If she cannot make the decision herself, her healthcare representative or legal decision-maker should participate according to her previously expressed wishes and goals of care.
Replacing a pacemaker generator when its battery is nearing the end of its life is another treatment decision. A replacement may maintain her heart rhythm and, if she is pacemaker-dependent, could potentially extend her life. However, it will not cure her underlying condition, reverse advanced decline, or necessarily improve her comfort or quality of life. The important question is not simply, “Can the pacemaker be replaced?” but, “Will replacing it help her live in a way she would consider meaningful, and do the possible benefits outweigh the procedure’s burdens?”
-Diane
The family should request a goals-of-care meeting with her cardiologist, primary physician, and hospice or palliative-care team. Helpful questions include:
- Does she have a pacemaker, an ICD, or a combined device?
- Is she completely dependent on the pacemaker?
- How much battery life remains?
- What would probably happen if the generator were not replaced?
- Would replacement improve her comfort or function, or primarily maintain her heartbeat?
- What are the risks and burdens of the procedure in her present condition?
- What did she previously say she would want if treatment could prolong life without improving its quality?
- Choosing not to replace the generator—or requesting deactivation when medically and ethically appropriate—is not the same as causing her death. It is a decision to allow the underlying illness to follow its natural course while care remains focused on comfort, dignity, and relief of distress. No decision should be made without a clear discussion with the clinicians who know her condition and the exact type of cardiac device she has.
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Pacemakers and End-of-Life Care: What Families Should Know
Every situation is different. The effect of a cardiac device at the end of life depends on the type of device, why it was implanted, the person’s underlying medical conditions, and whether the person depends on it to maintain an adequate heartbeat.
What Does a Pacemaker Do?
A pacemaker is a small, battery-powered device that monitors the heart’s electrical activity. When it detects that the heart is beating too slowly, it sends a mild electrical impulse that prompts the heart to beat.
A pacemaker can help regulate the heart’s rhythm, but it does not take over all the work of the heart. It cannot:
- Make a severely weakened heart pump normally
- Reverse advanced illness or frailty
- Prevent the kidneys, lungs, brain, or other organs from failing
- Stop the natural dying process once the body is shutting down
- Guarantee a better quality of life
As death approaches, the heart muscle eventually becomes too weak to respond effectively to the pacemaker’s electrical signals. The pacemaker may continue to send impulses, but it cannot keep the entire body functioning.
A Pacemaker Is Not the Same as a Defibrillator
Families should ask whether the person has a standard pacemaker, an implantable cardioverter-defibrillator called an ICD, or a device that performs both functions.
An ICD can deliver a strong electrical shock when it detects a dangerous heart rhythm. These shocks can be painful and distressing during the final stage of life. For that reason, the healthcare team may recommend turning off the ICD’s shock function when care becomes focused on comfort.
Turning off the shock function of an ICD does not necessarily turn off its pacemaker function.
If the family does not know which device is present, the cardiologist or device clinic can identify it through the medical record, the patient’s device-identification card, a chest X-ray, or a device interrogation.
Will a Pacemaker Be Turned Off When Someone Enters Hospice?
A pacemaker is not automatically turned off when someone enters hospice, has a Do Not Resuscitate order, or begins actively dying. In many cases, the pacemaker remains in place and continues functioning without interfering with a peaceful, natural death.
A DNR order applies to whether CPR will be attempted after breathing or heartbeat stops. It does not automatically deactivate a pacemaker or an ICD. Decisions about a cardiac device must be discussed separately.
Pacemaker deactivation is an individualized medical and ethical decision. It should involve the patient whenever possible, or the legally authorized healthcare decision-maker if the patient can no longer communicate. The cardiologist and hospice or palliative-care team should explain what may happen before any decision is made.
What Does “Pacemaker-Dependent” Mean?
Some people have an underlying heartbeat that can continue without the pacemaker. Others are considered pacemaker-dependent because their heart cannot maintain an adequate rhythm without it.
A device interrogation can help determine:
- What type of device is implanted
- How frequently it is pacing the heart
- Whether the person is pacemaker-dependent
- How much battery life remains
- Whether the device can deliver defibrillator shocks
- What could happen if it is not replaced or is deactivated
If a person is pacemaker-dependent, deactivating the device—or deciding not to replace a depleted generator—could shorten that person’s life. The likely effects and timing vary and should never be predicted without an individualized medical evaluation.
Should the Pacemaker Generator Be Replaced?
When a pacemaker battery is nearing the end of its service life, the generator can often be replaced through a procedure that is less involved than the original implantation. However, the fact that replacement is technically possible does not always mean it is the best choice.
Replacing the generator may maintain the heart rhythm and could prolong life, especially for someone who is pacemaker-dependent. However, replacement cannot reverse a terminal illness, advanced dementia, severe frailty, progressive organ failure, or an overall decline in health.
The decision should consider:
- The person’s overall prognosis
- Current comfort and quality of life
- The benefits the replacement is expected to provide
- The risks and burdens of the procedure
- Whether hospitalization or sedation would cause additional distress
- The person’s previously expressed values and wishes
- Whether the goal of care is treatment, comfort, or a combination of both
The central question is not simply, “Can the pacemaker be replaced?” It is, “Will replacing it help this person live in a way they would consider meaningful, and do the expected benefits outweigh the burdens?”
What Happens During the Natural Dying Process?
When the body begins its natural decline, several systems gradually slow down. Families may notice:
- Increasing sleep and reduced responsiveness
- Less interest in food and fluids
- Difficulty swallowing
- Decreased urine output
- Increasing weakness
- Confusion, restlessness, or withdrawal
- Cooler or mottled hands and feet
- Lower blood pressure and weaker circulation
- Irregular, shallow, or noisy breathing
- Longer pauses between breaths
These changes are generally caused by the underlying illness and the body’s organs losing their ability to function. They are not usually caused by the pacemaker.
A pacemaker may continue to stimulate the heart during part of this process, but it cannot restore circulation when the heart muscle and other organs can no longer function. In most circumstances, a pacemaker alone does not prevent a natural death.
Questions Families Should Ask
Families can request a goals-of-care meeting with the cardiologist, primary medical provider, and hospice or palliative-care team. Useful questions include:
- What exact type of cardiac device is present?
- Does it include a defibrillator that can deliver shocks?
- Is the person pacemaker-dependent?
- How much battery life remains?
- What benefit would replacement provide at this stage?
- Could the procedure improve comfort or function?
- What risks or burdens would replacement create?
- What would likely happen if the generator were not replaced?
- Should an ICD’s shock function be turned off?
- Do the current advance directive and healthcare power of attorney address this decision?
- How will symptoms be managed if treatment is declined or the device is deactivated?
Choosing Comfort-Focused Care
Choosing not to replace a pacemaker generator, or requesting device deactivation when medically and ethically appropriate, is not the same as abandoning the person or causing their underlying illness.
It means deciding that additional medical intervention may no longer support the person’s values or goals. Nursing care, medications, emotional support, spiritual care, and relief of pain, breathlessness, anxiety, or agitation should continue.
No family should have to make this decision without clear information and professional support. If a person has a serious or terminal illness, ask for a palliative-care or hospice consultation before a crisis occurs. Whenever possible, discuss and document these preferences while the person can still express their own wishes.
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