The management of implantable cardiac devices at the end of life

In the past 10 years, implantable devices that augment cardiac function and/or treat lethal arrhythmias have become standard therapies for end-stage heart failure. These devices include implantable cardioverter defibrillators (ICDs), bi-ventricular pacemakers for cardiac resynchronization therapy (CRT) and ventricular assist devices (VADs). Each of these devices presents unique challenges in the palliative care setting. As the volume of device implants increases and more patients with these devices reach the end of their lives, device management issues become more pertinent in the palliative care setting. This review will discuss the nature and differences of ICDs, CRT devices and VADs, specific issues pertaining to device de-activation, and strategies for management at patients' end of life. Provision of high-quality care for these patients will require increased collaboration between cardiovascular and palliative care specialists.