Defibrillati|on|off

Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.—Isaac Asimov

Today, 1 in 5 of us will develop heart failure, a diagnosis that has until recently carried a grave prognosis; however, we now have multiple therapies to improve both morbidity and mortality in this cohort. We know that the use of implantable cardioverter defibrillators (ICDs) can reduce the risk of sudden cardiac death in selected patients with heart failure.^2,3 In the early 2000s, results from the ICD trials were met with almost universal enthusiasm, and implantation rates soared; however, decisions on ICD implantation in patients with complex conditions continued to provoke debate in practice. In part, these arguments concerned uncertainties about what we should do when an eligible patient might be exposed to harm. “What goes up, must come down,” said Isaac Newton. Similarly, the implantation and activation of an ICD must be followed by its deactivation. Current decisions on ICD deactivation are usually solely evidence based and do not consider that we know that some patients, often approaching the end of their lives, will not reasonably benefit from any therapy an ICD can deliver.