Devices Can Interfere With Peaceful Death

Other times the devices are not deactivated because patients and families are torn. They may not accept that death is inevitable. They may fear the decision will result in immediate death. Some patients, even if they are being tormented by repeated shocks, just see the devices as different from other care.

"Patients develop a complex relationship with these devices. It's inside them. They have been told this device is going to be with them to save their life. It becomes like a trusted friend," Goldstein said.

Earlier this month, Cathryn Devons finally decided to ask doctors at Mount Sinai Hospital to deactivate her 92-year-old father's device after it started going off repeatedly.

"It would be cruel to shock him continually in his last day of life," said Devons, a physician at the hospital. "He was dying, and the defibrillator became an obstacle to his dying in peace."

Although Devons encountered no difficulty getting the device shut off, patients and family members can meet resistance from cardiologists, who are sometimes uncertain whether it is ethical or liken the act to physician-assisted suicide.

"I've heard some doctors say they believe the device has become part of the patient's natural landscape -- somehow part of the patient's physiological makeup," Ballentine said. "They feel like tampering with it is a more active intervention, which makes them uncomfortable."

The logistics of getting an ICD turned off can also be difficult, especially with a bedridden or comatose patient.

Some doctors and nurses will go to a patient's home to deactivate the device, and companies that make ICDs will send a technician as long as there is a written order from a doctor and a physician or nurse is present. But officials from the three companies that sell ICDs in the United States -- Medtronic Inc., St. Jude Medical and Boston Scientific Corp. -- said they are hesitant to recommend that doctors discuss the issue at the time of implantation.

"We agree this is an important issue, but this gets into the practice of medicine, and we don't think it's our job to practice medicine," said David Steinhaus of Medtronic. "That's a decision that should be made between individual patients and their physicians."

At St. Jude, however, Mark D. Carlson said the company is considering training technicians how to deal with such cases, adding: "We expect this to happen more often in the future."