The use of advance directives and do not resuscitate orders when considering the inactivation of implantable cardioverter-defibrillators in terminal patients

Thoughts about cardiac devices such as implantable cardioverter-defibrillators routinely focus on matters of patient benefit and quality of life while the device is in its operational ("on") state. If however, these devices are no longer serving to positively influence patient quality of life and are no longer clinically indicated from the standpoint of palliative care, difficult discussions can arise about device inactivation. While clinical ethics literature is replete with guidance on withdrawal of non-implanted therapies, such as dialysis and artificial ventilation, there has been minimal discussion involving the deactivation of such implanted therapies as cardioverter-defibrillators.