Life-saving devices reach the end of life with heart failure.

The new millennium has seen a dramatic increase in use of potentially life-prolonging devices such as implantable cardioverter-defibrillators (ICDs) and ventricular assist devices (VADs) among patients with advanced heart failure. Most patients who receive these devices will have them in place when they die. Clinicians who care for these patients must commit through the entire course of therapy, including the end-of-life. Discussions about device deactivation should be the standard of care and this discussion should take place prior to implantation, during annual heart failure reviews, after major milestones, and when the end-of-life appears to be approaching. Turning off ICDs and turning off VADs in response to patient or proxy requests are legally the same although they may be perceived differently, as disconnection of the VAD is more likely to cause immediate death. This article discusses the evidence around device deactivation at the end-of-life and offers suggestions for improvement.