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Deactivating Cardiovascular Implantable Electronic Devices (CIEDs) for Adult Inpatients (not during surgery or procedures) (2.3.26)

Deactivating Cardiovascular Implantable Electronic Devices (CIEDs) for Adult Inpatients (not during surgery or procedures) (2.3.26) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.26


UW HEALTH CLINICAL POLICY 1
Policy Title: Deactivating Cardiovascular Implantable Electronic Devices (CIEDs) for
Adult Inpatients (not during surgery or procedures)
Policy Number: 2.3.26
Category: UW Health
Type: Inpatient
Effective Date: May 26, 2017

I. PURPOSE

To provide guidance for the deactivation of a cardiovascular implantable electronic device (CIED) for adult
inpatients choosing to forgo resuscitation measures or requesting withdrawal of life sustaining treatment.

This policy is not intended for the deactivation of CIEDs for patients having surgery or other procedures in
which a CIED may be re-programmed for patient safety or other reasons related to the surgery or procedure.

II. POLICY ELEMENTS

CIEDs may be discontinued per the patient’s wishes, including prior wishes expressed either informally or in
an Advance Directive (see UWHC policy #4.37, Advance Directives) near the end of a patient’s life after an
informed discussion about the decision in the context of the patient’s goals. Withdrawal of life sustaining
treatment is discussed in more detail in UWHC policy #8.25, Guidelines for Decisions to Limit Life-
Sustaining Medical Treatment.

III. PROCEDURE

A. Shared Decision-Making: When considering the deactivation of a CIED, the attending physician or his or her
designee should engage the patient and the patient’s family or if the patient lacks capacity, the patient’s
legal representative or other surrogate decision-maker in a discussion about goals of care including Do Not
Resuscitate (DNR) status. This discussion should employ shared decision-making including a frank
discussion of the risks, benefits, alternatives and likely outcomes including the possibility of a shortened life.
i. When the patient is near the end of life, considerations include:
a. Defibrillator deactivation is often performed to ensure a patient is not subjected to painful
shocks from the device at the end of life.
b. Implanted Pacemakers:
1. For pacemaker-dependent patients, deactivation of pacing could result in
accelerated death and requires a careful discussion with the patient and family.
2. It is important to realize that pacemakers generally do not prolong the dying
process. For many patients, the pacing function may not need to be deactivated
to ensure alignment with the patient’s wishes.
3. Adjustments may be appropriate to slow the rate of pacing or turn off pacing
under certain circumstances.
B. Placing an Order: The attending physician or his or her designee must place an order in the clinical record to
make programming changes to the CIED including deactivation of pacing or defibrillation. When placing the
order electronically, the attending physician or his or her designee should search for “device” and select
“pacemaker/ICD/Loop Recorder (DEVICE)”.
C. Calling the Device Nurse or Cardiovascular Medicine Fellow: A member of the patient’s primary medical
team must also contact the Device Nurse or Cardiovascular Medicine Fellow verbally to confirm the order
i. In the paging directory on U-Connect, search for “pacemaker/ICD interrogation” in the “On-Call
Schedule Search” box to find out who to page. Click on the link to the pager. If paging directory is
not accessible/available:
a. During Normal Business Hours- Call the UH Cardiovascular Medicine Clinic at (608) 263-
1530 and ask for a Device Nurse.
b. After Hours- Call the Paging and Message Center at (608) 262-2122 and ask for the
Cardiovascular Medicine (CVM) Fellow On-Call.
ii. The Device Nurse or CVM Fellow will program the ordered changes into the device and document
the changes in the patient’s clinical record.
iii. See III, D, below if the Device Nurse or CVM Fellow is not immediately available to deactivate an
implanted cardiac defibrillator (ICD).
D. For The American Center (TAC):
i. The UW Electrophysiology (EP) attending physician on call will be consulted by the TAC



UW HEALTH CLINICAL POLICY 2
Policy Title: Deactivating Cardiovascular Implantable Electronic Devices (CIEDs) for Adult Inpatients (not during
surgery or procedures)
Policy Number: 2.3.26

ED provider or Hospital Medicine provider over the phone. The patient may either require
transfer to University Hospital (UH) for further EP care or receive an on-site evaluation.
E. Deactivation of an ICD by an Externally Placed Magnet:
i. The placement of a specialized magnet is a temporary, short-term method to deactivate an
implanted ICD. Placement of a specialized magnet over an ICD stops the device from
defibrillating the patient as long as the magnet remains directly over the device.
a. Note: This magnet will not stop or deactivate the implanted pacemaker. The magnet,
when placed directly over an implanted pacemaker, may temporarily place the device into
an asynchronous mode, which may result in continuous pacing at a fixed rate.
ii. The specialized magnet is typically about the size of the palm of a hand, circular and about an inch
thick. It can be found on the Cardiac Medical and Cardiothoracic Surgical Intensive Care Units
(F4M5 and B4/5) and the Heart and Vascular Procedure Center (cath lab) at UH and the overnight
care unit at TAC.
iii. If the Device Nurse or CVM Fellow is not immediately available to reprogram an implanted cardiac
defibrillator (ICD) or the ICD mode of a pacemaker defibrillator:
a. The Device Nurse or CVM Fellow on-call will write a nursing communication order and
direct the RN or a provider to place the specialized magnet directly over the ICD on the
skin. If a provider places the magnet, then he or she must promptly notify the patient’s RN.
b. The RN will inform the patient and/or family of the purpose of the magnet.
c. The magnet should be taped in place so it will not move. The magnet placement and
skin/area around the magnet should be monitored for correct positioning of the magnet
and for any skin breakdown with routine patient assessment while the magnet is in place.
d. The RN will write a progress note stating when the magnet was placed.
e. When the Device Nurse or CVM fellow re-programs the ICD, he or she will remove the
magnet.
1. The RN should clean the magnet with hospital disinfectant and return it to the
unit from which it came.
2. The Device Nurse or RN will inform the patient and/or family the ICD has been
re-programmed and magnet has been removed.
3. The Device Nurse or RN will document the removal of the magnet.
f. If the magnet remains on the patient for more than 24 hours or is causing any skin
irritation or breakdown, re-page the Device Nurse or CVM Fellow on-call.
g. When the Device Nurse or CVM Fellow re-programs the CIED, a note will be placed in the
patient’s clinical record.
1. Note: If the CIED is a combined defibrillator and cardiac resynchronization
therapy (also known as biventricular- implanted cardiac defibrillator (BiV-ICD) or
cardiac resynchronization therapy-defibrillator (CRT-D)), the specialized magnet
stops defibrillation but has no effect on pacing.
2. If the CIED has only cardiac resynchronization pacing (no ICD) known as a BiV
pacer or CRT-P, placing a magnet over the device will result in asynchronous
pacing like the effect of the magnet on a standard implanted pacemaker.
F. Consider a consult to the UWHC Ethics Committee when disagreement or conflict arises surrounding the
deactivation of a CIED. For additional information, refer to UWHC policy #8.25, Guidelines for Decisions to
Limit Life-Sustaining Medical Treatment.

IV. COORDINATION

Author: Clinical Nurse Specialist, Medical Cardiology
Senior Management Sponsor: VP, Chief Nursing Officer Inpatient
Reviewers: Medical Director, Palliative Care; Medical Director, Electrophysiology, Division of
Cardiovascular Medicine; Senior Risk Management Consultant; Device Nurse; Clinical Nurse Specialist,
Oncology; Clinical Nurse Specialist, Cardiac Surgery and Transplant;
Approval committees: Ethics Committee, UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: April 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics



UW HEALTH CLINICAL POLICY 3
Policy Title: Deactivating Cardiovascular Implantable Electronic Devices (CIEDs) for Adult Inpatients (not during
surgery or procedures)
Policy Number: 2.3.26

and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

UWHC policy #8.25, Guidelines for Decisions to Limit Life-Sustaining Medical Treatment
UWHC policy #4.37, Advanced Medical Directives
Alhammad, N.J., O’Donnell, M., O’Donnell, D., Mariani, J.A., Gould, P.A. & McGavigan, A.G. (2016).
Cardiac implantable electronic devices and end-of-life care: an Australian perspective. Heart, Lung and
Circulation, 25: 814-819.
Gura, M. (2015). Considerations in patients with cardiac implantable electronic devices at end of life. AACN
Advanced Critical Care, 26(4): 356-363.
Lampert, R., Hayes, D.L., Annas, G.J., Farley, M.A., Goldstein, N.E. et al. (2010). HRS expert consensus
statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing
the end of life or requesting the withdrawal of therapy. Heart Rhythm, 7(7): 1008-1026.
Westerdahl, A.K., Sutton, R. & Frykman, V. (2015). Defibrillator patients should not be denied a peaceful
death. International Journal of Cardiology, 182: 440-446.

VII. REVIEW DETAILS
Version: Revision
Last Full Review: May 26, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital Administrative policy #8.99