Philadelphia, PA - The wrong time to start thinking about it is when it's time to make the decision, according to a series of letters on the tough issue of implantable cardioverter-defibrillator (ICD) deactivation in patients near the end of life, published in the November 1, 2005 issue of the Annals of Internal Medicine [1,2,3].

They were responding to a case report and editorial in the same journal earlier this year that called for clinical guidelines to help physicians and patients avoid the tragedy of continued ICD firing when death is preferred [4].

In her letter, Dr Joanne Lynn (RAND Health, Arlington, VA) observes that the need for deciding whether to turn off an ICD "is a predictable part of the course of dying for any patient with an ICD who will die a natural death."

She related a story that may represent a worst-case scenario for the consequences of failing to plan ahead. "Recently, a hospice patient with cancer endured more than 50 shocks in the last day of life, anguishing between shocks as to whether stopping the now-hated device amounted to a mortal sin. Although that is a challenging question, surely it would be better contemplated back at the time of implantation . . . rather than having patient, family, and caregivers caught up in such torment."

Lynn writes that patients should be informed at ICD implantation "that this device should ordinarily be stopped when life is getting to be short and life's continuation is tenuous because of conditions other than arrhythmia or when dying with an arrhythmia becomes a better course than what otherwise awaits."

In another letter, Dr James M Beattie (Heartlands Hospital, Birmingham, UK) and associates suggest other opportunities for discussing the issue with the patient: when other forms of resuscitation are discussed, after withdrawal of antiarrhythmic therapy, or "on recovery from a crisis typical of the heart-failure-disease trajectory."

"We have recently incorporated ICD deactivation as a formal element of the Liverpool Care Pathway for the care of those dying of heart failure in the hospital," the group writes, "and we will soon pilot this protocol in a multicenter study in England."

Replying to the correspondents in his own letter, the original report's author, Dr Jeffrey T Berger (Winthrop University Hospital, Mineola, NY), observes that there are numerous barriers to effective advance planning, including "widespread public reluctance" to discuss the issue and "culturally based discordance with advance directives."

"These challenges should not dissuade professionals from discussing treatment preferences with their patients," he writes. "Rather, the health and legal systems should better integrate advance planning as well as family decision-making processes for patients who choose not to plan."