A pacemaker does not stop working the moment its owner dies. The device has its own battery and internal logic, so it continues sending electrical impulses to the heart even after the heart can no longer respond. For a standard pacemaker, this is quiet and harmless, but for an implantable cardioverter-defibrillator (ICD), the consequences can be far more dramatic and distressing. What happens next depends on the choices made before death, the plans for the body afterward, and sometimes the needs of a forensic investigation.
The Device Keeps Firing
A pacemaker is designed to monitor heart rhythm and deliver small electrical pulses when the heartbeat is too slow or irregular. It has no way of knowing its owner has died. After death, the heart muscle stops contracting and eventually becomes unresponsive to electrical stimulation, but the pacemaker’s pulse generator keeps doing its job, sending signals into tissue that can no longer respond. For a basic pacemaker, this is invisible to anyone in the room. The tiny electrical pulses are too weak to cause visible movement, and the device simply runs down its battery over weeks or months inside the body.
An ICD, however, is a different story. These devices are built to detect dangerous heart rhythms and deliver a powerful shock to reset them. When the heart stops beating normally at death, the ICD may interpret the resulting electrical chaos as a shockable rhythm. It can then fire repeatedly, sending jolts strong enough to make the body visibly jerk. A survey of Oregon hospices documented cases where ICDs shocked patients during and even after the dying process, causing the body’s arms and legs to flail. One hospice aide described wrapping a deceased man’s body tightly to stop the movement while his distraught wife watched.
Why Deactivation Before Death Matters
The possibility of post-mortem shocks is the main reason clinicians recommend discussing ICD deactivation well before a patient reaches the end of life. Turning off the shock function of an ICD is a straightforward procedure, usually done by placing a programming wand over the device. It does not affect any pacing function the device provides, so the patient’s heart rate support continues. Only the high-voltage shock therapy is disabled.
Despite how simple the process is, conversations about deactivation happen far less often than they should. A study of hospices across the United States found that only about one in ten had a formal policy addressing ICD deactivation. Hospices with a written policy saw a much higher rate of deactivation: roughly three-quarters of their ICD patients had the shock function turned off, compared to just over a third at hospices without one.
Families and patients sometimes worry that deactivating a cardiac device is equivalent to giving up or hastening death. Legally and ethically, it is neither. Deactivating an ICD or pacemaker at a patient’s request falls under the well-established right to refuse or withdraw medical treatment. Courts and medical ethicists draw no meaningful distinction between withdrawing a cardiac device and withdrawing other life-sustaining therapies like ventilators or dialysis. It is not considered euthanasia or assisted suicide.
What Happens to the Device After Death
Once someone with a pacemaker or ICD dies, the device usually needs to come out of the body. Whether it must be removed depends almost entirely on what will happen next. If the body is going to be buried, removal is not strictly required in most places, though families or funeral directors may still choose to have it explanted. If cremation is planned, removal is essentially mandatory.
The reason is simple: pacemakers and ICDs contain sealed lithium batteries and, in the case of ICDs, capacitors that store significant electrical charge. When exposed to the extreme heat of a cremation furnace, these components can explode. The blast is powerful enough to damage the furnace lining and send shrapnel flying. A survey of crematoria across the United Kingdom found that roughly half had experienced a pacemaker explosion. Most crematorium staff were aware of the risk from standard pacemakers but, alarmingly, many did not realize that ICDs pose an even greater hazard because of their larger batteries and high-voltage capacitors.
Because of this risk, cremation paperwork in many countries includes a specific question about whether the deceased had an implanted cardiac device and whether it has been removed. Funeral directors and morticians routinely handle device removal. A survey of morticians found that each one removed an average of about seven devices per year, with some handling as many as fifty annually.
The Challenge of Newer Devices
Traditional pacemakers sit in a small pocket under the skin of the chest, usually just below the collarbone, with wire leads threaded through veins into the heart. They are relatively easy to locate and remove. Newer leadless pacemakers, however, are tiny capsules implanted directly inside the heart itself. They have no visible bump under the skin and no leads to trace.
This miniaturization creates a real problem after death. Identifying and retrieving a leadless pacemaker from inside the heart is considerably more difficult than cutting out a traditional device from a chest pocket. Case reports have highlighted the practical difficulties in localizing and extracting these novel devices before cremation. Because they still contain batteries capable of exploding under heat, they carry the same cremation risk as their larger predecessors, but they are much harder to find and get out.
One practical solution that has been studied is the use of handheld metal detectors. Research has shown that simple, inexpensive metal detectors are effective at identifying the presence of a cardiac device in a deceased person, even when medical records are incomplete or unavailable. For crematorium staff or funeral directors who may not have access to the patient’s medical history, a quick scan of the chest can catch a device that might otherwise be missed.
Where Do Removed Devices Go
After a pacemaker or ICD is taken out of a body, it can follow several different paths. The survey of morticians found that the most common destination was medical waste, accounting for just under half of explanted devices. But a meaningful share, about one in five, were donated for reuse in developing nations.
Pacemaker reuse is a subject that generates strong opinions. In wealthy countries, devices are implanted new and used by one patient for their lifetime. But a pacemaker removed after death often has years of battery life remaining. In low- and middle-income countries where patients cannot afford new devices, a recycled pacemaker can be the difference between treatment and none at all. Research into the practice has found no increased risk of complications or death when properly sterilized and tested devices are reimplanted.
The practice has its complications, though. The U.S. Food and Drug Administration, device manufacturers, and several professional medical societies have historically encouraged the return of explanted devices to the manufacturer rather than reuse. Their reasoning centers on maintaining accurate performance databases: if a manufacturer does not get its devices back, it cannot track long-term failure rates and improve future designs. Donation programs that send devices abroad must navigate this tension between individual patient benefit and the broader safety ecosystem.
Forensic Value of a Dead Person’s Pacemaker
Modern pacemakers and ICDs are not just therapy devices. They are also continuous cardiac monitors, recording detailed logs of heart rhythm data, sometimes stretching back months. After a person dies, interrogating their device (downloading its stored data using the same programmer used during routine clinic visits) can reveal exactly what the heart was doing in the final minutes and hours of life.
This capability has proven valuable in forensic investigations. In at least one documented homicide case, interrogation of a victim’s pacemaker helped investigators establish the precise time of death and reconstruct the sequence of events leading up to it. The device’s internal clock and rhythm logs provided a level of temporal precision that other forensic methods could not match.
Beyond criminal cases, post-mortem device interrogation is useful for understanding sudden cardiac death more broadly. A systematic review of studies on the topic found that dangerous heart rhythms were recorded in about a third of all devices that were successfully interrogated after death, and in nearly two-thirds of people who experienced sudden cardiac death specifically. Interestingly, a substantial portion of recorded dangerous rhythms were found in people whose deaths were not classified as sudden cardiac death, suggesting that arrhythmias play a role in more deaths than might be initially suspected. Making sense of these recordings, though, requires combining the device data with autopsy findings; the rhythm log alone does not always tell the full story.
Practical Decisions for Patients and Families
If you or a family member has a pacemaker or ICD, a few practical points are worth knowing. First, make sure your funeral director knows about the device. Even if you are planning burial rather than cremation, the information matters for handling the body and for any decisions about donation or return to the manufacturer. If cremation is the plan, removal is not optional, so confirming this is handled early avoids last-minute complications.
Second, if end-of-life care is on the horizon, bring up ICD deactivation with the medical team. This conversation is often overlooked, partly because doctors themselves may not think to raise it and partly because families may not realize it is an option. The shock function can be turned off quickly and painlessly, and it prevents the deeply upsetting scenario of a dying or recently deceased person being repeatedly shocked. Pacing support can continue if desired, so the patient does not lose their heart rhythm support.
Third, consider specifying your wishes about the device in an advance directive. Some advocates have proposed the idea of a “pacemaker living will,” a document that states what should happen to the device if the patient becomes unable to make decisions: whether the shock function should be turned off, whether the pacing should continue, and what should happen to the device after death. This is not yet a standard part of advance care planning in most healthcare systems, but it is a conversation worth having with your cardiologist and your family.
The Gap Between What Should Happen and What Does
The biggest issue with pacemakers and death is not technical. The devices can be deactivated, removed, interrogated, and recycled with existing technology and protocols. The gap is in communication. Patients are not told about deactivation options. Hospice staff are not trained on what to do when an ICD fires on a dying patient. Crematorium workers may not know that leadless pacemakers exist or that ICDs are more dangerous than standard pacemakers. Morticians may not have clear guidance on whether to return a device to the manufacturer or donate it.
Each of these failures has real consequences. Families witness traumatic post-mortem shocks that could have been prevented by a five-minute conversation weeks earlier. Crematorium furnaces are damaged by explosions that a simple metal detector sweep could have avoided. Thousands of functional devices with years of remaining battery life end up in medical waste bins while patients in other countries die for lack of a pacemaker. The technology is not the problem. The systems around it, the conversations, the policies, the forms, have not kept pace with the devices themselves.
Pacemakers in the Autopsy Suite
Pathologists who perform autopsies on patients with cardiac devices follow specific protocols that differ from standard post-mortem examinations. The device must be identified, its type determined (pacemaker versus ICD versus combination device), and, in the case of an ICD, its shock function must be confirmed as disabled before anyone handles the heart. An active ICD can discharge during autopsy, delivering a shock to the pathologist or technician. The stored charge in an ICD’s capacitors can persist for some time after death, making this a genuine occupational hazard rather than a theoretical one.
Once the device is safely retrieved, it can be interrogated to pull its stored data. For the pathologist, this data can clarify whether a cardiac arrhythmia contributed to death, which is particularly useful in cases where the anatomical findings at autopsy are ambiguous. A heart that looks structurally normal under the microscope may still have been the site of a lethal rhythm disturbance, and the device log may be the only evidence of that. The integration of device data with traditional autopsy findings represents a relatively new tool in forensic and clinical pathology, and it is one that is becoming more important as the number of people living with implanted cardiac devices continues to grow.