At what point should you consider deactivating ICDs or implanted pacemakers in patients nearing the end of life but not imminently dying?

Great question. I’ll start with the second part first. This should be a unique point in your discussions. You should clarify whether or not they want the ICD turned off, even if they agree to comfort care measures. If they hesitate to turn the ICD off, take this as an opportunity to explore more. Why are they hesitant to turn it off? Perhaps it’s because they aren’t actually aligned with comfort care, and this would mean needing to re-address goals of care. Some people are hesitant because they think it’ll hasten death, which it does not; it simply allows nature to take its course without our interference.

As to when to address deactivating ICDs, I can think of several scenarios:

1. Someone has chosen to pursue comfort measures in the hospi...