The primary function of pacemakers is to treat bradyarrhythmias (e.g., heart block). More recently, patients with heart failure, subvalvular stenosis, and treatment-resistant atrial fibrillation may qualify for pacemakers. Additionally, patients with congestive heart failure may receive biventricular pacemakers to improve symptoms.

Pacemaker function at time of death
In general, contrary to popular belief, pacemakers do not keep dying patients alive. At the time of death, the myocardium is usually too sick to respond to the pacemaker generated signals. Also, at the time of imminent death tachycardia is more common.

When is pacemaker deactivation indicated?
In patients with irreversible cognitive failure where continued pacemaker activity is not meeting the goals of care deactivation may be discussed. In most other situations, deactivation is not indicated as the result may be symptomatic bradycardia, fatigue, dizziness, or dyspnea.
It is important to make a distinction between pacemakers and Implantable Cardioverter Defibrillators (ICDs) when providing the patient with information. The deactivation of a pacemaker may be likely to induce symptomatic bradycardia and a poorer quality of death, whereas deactivating an ICD is unlikely to decrease quality of life.

Ethical/legal issues
The right of a patient or their surrogate to request withdrawal of life-sustaining medical interventions, including pacemakers, is both legal and ethical. This is not physician-assisted suicide or euthanasia.

Adapted from Harrington MD, Luebke DL, Lewis WR, Aulisio MP, Johnson NJ. Palliative Care Network of Wisconsin. Fast facts and concepts #111. Cardiac pacemakers at the end-of-life. Internet. Accessed on June 21, 2016.