Pacemaker and defibrillator management in medical assistance in dying: Review for the primary care provider

Cardiovascular conditions are highly prevalent in patients who are eligible for medical assistance in dying. Within this population, cardiac implantable electronic devices are common. Thus, there is a need to understand the physiological effects of these devices in patients who choose medical assistance in dying, and the role and scope of reprogramming, deactivation, and other management strategies for the devices. The drugs used in medical assistance in dying result in a cascade of physiological effects that result in loss of myocardial contractility.The cardiac implantable electronic device may continue to electrically activate the heart, but a contraction will not result, and the heart will not effectively pump blood. These devices have adjustable parameters to optimize performance, which may be changed with special computers or can be reprogrammed with unique magnets. At the tinne of medical assistance in dying, a permanent pacemaker will electrically stimulate the heart, but eventually, the myocardium will no longer contract. Placing a magnet over an implantable cardioverter defibrillator disables the device's ability to detect ventricular arrhythmia and helps avoid any defibrillation during dying. Understanding the consequences of deactivating the defibrillating function of the device is important. If it is deactivated prematurely, the patient may die prior to their planned time and location. The process and options regarding cardiac implantable electronic devices deactivation or reprogramming, and potential manifestations at the time of medical assistance in dying should be discussed with the recipient, with the advice and support from the medical assistance in dying provider and cardiac implantable electronic devices clinic team member.