How to Turn Off a Pacemaker at End of Life

Turning off a pacemaker at the end of life is a medically and legally recognized option that any patient with decision-making capacity can request. The process is carried out by a physician or a device technician under a physician’s supervision, using a specialized programmer that communicates wirelessly with the implanted device. While the procedure itself takes only minutes, the conversation around it is often the harder part, involving family, clinicians, ethics consultations, and sometimes deeply personal beliefs about what it means to let go.

The Legal Right to Request Deactivation

In the United States, a patient with decision-making capacity has the legal right to refuse or request the withdrawal of any medical treatment, including a pacemaker or implantable cardioverter-defibrillator (ICD), regardless of whether the withdrawal leads to death. When a patient lacks the capacity to decide, a legally designated surrogate has the same right on the patient’s behalf.¹ This principle is grounded in the broader ethical and legal consensus that there is no meaningful difference between refusing a treatment before it starts and requesting its withdrawal after it has been in place.

A key point that trips people up: deactivating a pacemaker is not considered physician-assisted suicide or euthanasia. Major cardiology and heart rhythm societies explicitly state that when a clinician carries out a patient’s request to withdraw device therapy, the intent is to discontinue an unwanted treatment and allow the person to die of their underlying condition, not to end the person’s life.² This distinction matters practically because it means clinicians should not refuse the request on the grounds that it amounts to killing the patient. It also means the request can be honored in states or countries where assisted dying is not legal.

Pacemakers and ICDs Are Not the Same Decision

People often lump pacemakers and ICDs together, but the end-of-life calculus is quite different for each. An ICD monitors for dangerous heart rhythms and delivers an electrical shock to restore a normal beat. At the end of life, those shocks can become painful and distressing without meaningfully extending a dying person’s life. Deactivating the shock function of an ICD is widely considered straightforward from both an ethical and a clinical standpoint, and it can be done without affecting the ICD’s pacing function if the device also serves as a pacemaker.

A pacemaker, on the other hand, continuously supports the heart’s rhythm. Turning it off raises harder questions because some patients are what clinicians call “pacing dependent,” meaning their heart cannot maintain an adequate rhythm on its own. In those patients, deactivation could cause an immediate and significant drop in heart rate, potentially leading to symptoms like dizziness, fainting, or distress. One review noted that in pacing-dependent patients, deactivation could induce very low heart rates and symptoms of bradycardia, which is why pacemaker deactivation is more controversial and less commonly offered than ICD shock deactivation.³ Some health professionals view deactivating a pacemaker in a dependent patient as hastening death, even though the legal and ethical consensus treats it the same as withdrawing any other life-sustaining treatment.

Not every pacemaker patient is pacing dependent. Many people received their device years ago for intermittent symptoms, and their heart may still generate a functional rhythm without it. In those cases, turning the pacemaker off might produce no immediate change at all. Understanding where on this spectrum a patient falls is one of the first things the medical team assesses when the conversation begins.

Who Performs the Deactivation and How It Works

The actual process of deactivating a pacemaker is technically simple. A device programmer, which looks like a small laptop with a wand, is held near the patient’s chest. It communicates wirelessly with the implanted device and allows a technician to change its settings, including turning pacing off entirely or lowering its output so it no longer captures the heart. The procedure itself takes minutes and is painless.

The person operating the programmer is usually a cardiac electrophysiologist (a cardiologist who specializes in heart rhythm devices) or a trained device technician. In some settings, an industry representative from the device manufacturer may be asked to assist with deactivation. European guidelines make clear that this is permitted: upon the written order of an attending physician and under direct physician supervision, a manufacturer’s representative can carry out the deactivation.⁴ However, industry representatives and individual physicians have the right to conscientiously object to participating. If someone declines, the attending physician is responsible for finding another willing clinician or representative to carry out the request.

You might have heard that placing a magnet over a pacemaker can affect its function. This is true for some devices, but it is not a reliable method for deactivation. Some pacemakers have magnet-operated switches that temporarily shift the device to a fixed pacing mode, but magnet behavior varies widely between manufacturers and models. In some devices, the magnet response has been programmed off entirely.⁵ Placing a magnet over an ICD will typically suspend shock therapy for as long as the magnet stays in place, which can be useful as a temporary measure. But for permanent deactivation, the programmer is the tool of choice, and contacting the manufacturer is the most reliable way to understand how a specific device will respond to any intervention.

Having the Conversation Before a Crisis

One of the persistent problems in this area is that the conversation about deactivation happens too late, or not at all. Research involving nurses who care for patients with implanted cardiac devices found that many patients did not know their device could be deactivated. The topic was often addressed only reactively, after repeated ICD shocks for example, or when the patient had already become too ill to participate in their own decision-making.⁶

This is a significant gap. Ideally, the possibility of future deactivation should be discussed when the device is first implanted and revisited during routine follow-up visits as a patient’s health changes. Advance directives are the most concrete tool available. In a case series reviewing end-of-life device decisions, five out of six patients had advance directives indicating a desire to withdraw medical interventions if death became inevitable. Two patients made the request themselves, and four surrogates made it on behalf of patients who had lost decision-making capacity.¹ Of those whose requests were granted, all four died within five days of support being withdrawn.

If you or a family member has an implanted cardiac device, the most practical step you can take right now is to include specific language about the device in your advance directive. Generic instructions about “withdrawing life-sustaining treatment” are sometimes interpreted as not covering implanted devices, since they feel different from a ventilator or feeding tube to many clinicians and families. Naming the device explicitly removes ambiguity.

When Families and Clinicians Disagree

Not everyone agrees on when or whether to turn off an implanted device, and these disagreements can be agonizing. One published case involved a patient approaching the end of life who was regularly receiving painful ICD shocks. The clinical team recommended deactivation, but the patient’s family refused, citing a religious obligation to prolong life regardless of the risk of suffering.⁷ Cases like this create what ethicists call moral distress: clinicians feel they are prolonging suffering while family members feel they are honoring deeply held values.

Religious and cultural perspectives on device deactivation vary widely. Some traditions treat any withdrawal of life support as morally impermissible, while others view it as an acceptable part of allowing a natural death. There is no universal religious position. What complicates these situations further is that the legal framework generally gives the surrogate decision-maker the final word when the patient cannot speak for themselves. Ethics consultations can help, but they are advisory rather than binding. When the patient’s own wishes were documented in advance, those documents carry significant legal weight and can resolve many of these conflicts before they escalate.

What Palliative Care Teams Contribute

Palliative care specialists play a significant role in end-of-life device decisions, though they are not involved as often as they could be. One study found that about 42% of patients undergoing device deactivation received a palliative care consultation, and roughly two-thirds of those consultations specifically addressed the deactivation itself.⁸ That means the majority of patients went through the process without specialized palliative input.

What palliative care adds is help with the practical and emotional logistics. For pacing-dependent patients, deactivation might cause discomfort as the heart rate drops. Palliative teams can ensure that appropriate comfort medications are available and administered to manage any distress. They also help families understand what to expect in the hours or days following deactivation: for a pacing-dependent patient, death may come relatively quickly, while for someone whose heart still generates its own rhythm, the pacemaker’s absence might not change the timeline at all. Setting these expectations in advance prevents panic and confusion during an already emotional time.

For patients in hospice, particularly those at home, coordination is essential. The device technician or physician needs to be scheduled, comfort measures need to be in place, and the family needs preparation. Research on families who went through home-based pacemaker deactivation in hospice found that the hospice model of care and support contributed positively to the grieving process. None of the family caregivers in the study experienced complications in their grief, despite the added emotional and ethical weight of having participated in the deactivation decision.⁹

Conscientious Objection and Finding Willing Providers

Both the American and European guidelines recognize that individual clinicians and device representatives may have moral objections to deactivating a cardiac device. The guidelines are clear, though, that a provider’s objection does not override the patient’s right. If one clinician declines, the attending physician must arrange for another willing provider to carry out the request.⁴

In practice, this can create delays. Not every hospital or hospice has an electrophysiologist on staff, and rural settings may require scheduling a visit from a traveling technician or manufacturer representative. If you are planning ahead, it is worth confirming with your care team well in advance that someone who is both willing and technically capable of performing the deactivation will be available when the time comes. Hospice intake is a good moment to ask this question explicitly.

What Happens to the Device After Death

A pacemaker does not stop working just because the patient dies. The device will continue to emit electrical pulses for as long as its battery lasts, which can be years. This creates a practical issue: if the body is to be cremated, the device must be removed first. Pacemaker and ICD batteries can explode when exposed to the extreme heat of a cremation furnace, posing a risk to crematorium workers and equipment. Funeral homes routinely handle this. A survey of morticians found that the average funeral home removed about seven devices per year, with some handling as many as fifty.¹⁰

What happens to those devices afterward varies. The same survey found that the most common disposal method was placement in medical waste, accounting for about 44% of cases. Around 18% of explanted devices were donated for reimplantation in developing nations. Only 4% of morticians reported ever returning devices to manufacturers, though 87% said routine return to manufacturers would be feasible.¹⁰

Some researchers have argued that returning devices to manufacturers should be standard practice, not an afterthought. The reasoning is that analyzing returned devices can reveal product defects that might otherwise go undetected, potentially affecting other living patients with the same model. One ethical analysis argued that consent forms for device implantation should include a requirement for postmortem explantation and return to the manufacturer, and that failing to do so allows product defects to be hidden from patients, families, and regulatory agencies.¹¹ There are also environmental concerns, since buried devices contain lithium batteries and other materials that may leach into soil over time. This remains an area where practice has not caught up to the ethical arguments being made.

The Scale of the Issue

These are not rare conversations. More than 4.5 million people worldwide live with implanted pacemakers, including over 3 million in the United States alone. An additional 800,000 or more Americans have an ICD.¹² The vast majority of these patients are elderly and will eventually face end-of-life decisions. Yet despite decades of clinical experience and published guidelines, the evidence consistently shows that device deactivation remains under-discussed, poorly planned for, and inconsistently managed. The tools exist. The legal framework is settled. The gap is in the conversations that happen, or fail to happen, between patients, families, and their medical teams long before the final days arrive.