Should You Turn Off a Pacemaker or Defibrillator (ICD) on Hospice?

Turning off the shocking function of an implantable cardioverter-defibrillator (ICD) is a common, reasonable choice on hospice, because its shocks can cause painful jolts at the very end of life. A pacemaker, which gently keeps the heart in rhythm and does not shock, is usually left on. This is a personal decision made with your hospice physician, never something done without your consent.

The question can feel frightening because it sounds like switching off a life-support machine. In reality, the two devices do very different things, and only one of them—the ICD's shock—poses a real risk of causing pain at the end of life. Understanding that distinction is the key to a calm, well-informed choice, and the sections below walk through exactly what each device does, why families commonly deactivate the shocks, and how to arrange it without a crisis.

Pacemaker vs. ICD: they are not the same

These two devices are often confused, but they do different jobs, and the hospice approach differs accordingly.

Many modern devices are combination units that both pace and defibrillate. In that case, the clinician can switch off only the shocking feature while leaving the pacing function intact—so the heart still gets its gentle rhythm support without the risk of a painful jolt.

Why families deactivate the ICD's shocks

An ICD is built to interrupt sudden death by jolting the heart. At the end of life, when the body is naturally shutting down, that same shock can deliver repeated, painful jolts to a dying person, sometimes several in their final hours, without changing the outcome. Deactivating the shock function spares that suffering. It does not cause death; it simply stops the device from intervening against a natural dying process. This fits the comfort-focused goals of comfort care.

Deactivation is quick and painless. A technician or clinician places a programmer or magnet over the device and turns off the shocking feature. No surgery is needed, and any pacing function can be left untouched.

What deactivation does and does not do

Families often fear that switching off the ICD will cause an immediate death or leave their loved one unsupported. Neither is true:

• It does not cause death. It stops the device from shocking the heart; the underlying illness still follows its natural course.
• It does not turn off pacing. If the device also paces, that gentle, painless function can stay on so the heart keeps its rhythm support.
• It is reversible in principle, though families rarely reactivate once the goal is comfort. You remain in control of the decision.
• It prevents a specific harm: repeated, distressing shocks in the final hours that would not extend meaningful life.

For someone whose goals have shifted to comfort, deactivation simply aligns the device with those goals.

The misconception, corrected

Some families worry that turning off an ICD is "giving up" or even causing death. It is neither. The device was added to prevent sudden cardiac death in someone who was expected to live; when a person is dying of a terminal illness, the shocks no longer extend meaningful life and instead add pain. Choosing to deactivate is choosing comfort, and it is fully consistent with hospice care. Equally, no one will deactivate your device against your wishes; you remain in control.

Because heart devices are common in advanced cardiac disease, this question comes up often in hospice care for congestive heart failure. Discuss it early so the decision is unhurried.

How this fits the larger comfort plan

Deactivating an ICD's shocks is one piece of a broader shift toward comfort that defines hospice care for advanced heart disease. Alongside the device decision, the team focuses on relieving the symptoms that weigh on people with end-stage cardiac illness—breathlessness, fluid overload, fatigue, and anxiety—using medications and measures matched to comfort goals. You can read more about the medicines commonly used in this phase in common medications used in end-of-life care. Importantly, properly dosed comfort medications such as morphine relieve pain and breathlessness without hastening death, just as deactivating a defibrillator relieves the threat of painful shocks without causing death. Both reflect the same principle: removing sources of suffering while letting the underlying illness take its natural course. Seen this way, turning off the shocks is not a separate or dramatic act but a natural part of aligning every intervention with what your loved one actually wants near the end.

How the conversation usually unfolds

The smoothest path is to raise the device at admission rather than in a crisis. The hospice physician will ask exactly which device is implanted—a pacemaker, an ICD, or a combination unit—often confirming with the device card, the implanting cardiologist, or a quick interrogation of the device. They will explain what each function does and what deactivating the shocks would mean for your loved one's comfort. If you choose deactivation, the team arranges for a technician from the device company or the cardiology service to disable the shocking feature, frequently at the bedside or in the home. The decision is documented in the plan of care and, ideally, in the patient's advance directives so every clinician who later sees the patient knows the wishes. Doing this calmly, in advance, avoids the worst-case scenario: a dying patient receiving repeated shocks while a family scrambles after hours to reach someone who can turn the device off.

Frequently asked questions

Does turning off the ICD hurt?

No. Deactivation is painless and needs no surgery. A clinician places a programmer or magnet over the device to disable the shocking function. It takes only minutes and can be done at the bedside or at home.

Will my loved one's heart stop the moment the ICD is turned off?

No. Deactivating the shocks does not stop the heart or cause immediate death. It only prevents the device from delivering jolts; the heart continues on its own, and the underlying illness follows its natural course. If the device also paces, that support can remain on.

Should the pacemaker be turned off too?

Usually not. A pacemaker provides gentle, painless rhythm support and generally promotes comfort, so it is typically left on. The shocking function of an ICD is the part that can cause distress near the end of life. Your hospice physician can explain what is right for your loved one's specific device and goals.

What happens if we do nothing and the ICD stays active?

An active ICD may deliver one or more painful shocks as the heart's rhythm becomes unstable during the dying process, without changing the outcome. Many families find these jolts distressing to witness and to experience. That is precisely why the option to deactivate exists—to spare unnecessary suffering.

Does deactivating the ICD cost anything?

The hospice plan of care covers management related to the terminal illness, and arranging deactivation is part of that comfort-focused care. The only routine cost-sharing under the Medicare Hospice Benefit is up to $5 per prescription for comfort medications and 5% coinsurance for inpatient respite—not a charge for turning off a device. Ask the hospice team to confirm the specifics for your situation.

Your practical next step

Raise the device at admission, not in a crisis. Tell the hospice team exactly which device is implanted, and ask the hospice physician to explain your options and arrange deactivation if you choose it. Put your decision in writing as part of your advance directives so every clinician knows your wishes. Keep the hospice's 24/7 number handy, and if your loved one ever receives a shock, call the hospice line rather than 911. If you are still selecting a hospice, ask whether they have staff experienced with cardiac devices, and compare hospices near you on the strength of their clinical teams.