TERMINAL CARE Recommendations for Terminal Care References that support the recommendations are summarized in Online Data Supplement 59. COR LOE Recommendations I C-EO At the time of ICD implantation or replacement, and during advance care planning, patients should be informed that their ICD shock therapy can be deactivated at any time if it is consistent with their goals and preferences. I C-EO In patients with refractory HF symptoms, refractory sustained VA, or nearing the end of life from other illness, clinicians should discuss ICD shock deactivation and consider the patients goals and preferences. Synopsis A particularly challenging area of medicine is recogniz- ing when life-prolonging therapies may become bur- densome or even harmful. This is particularly true near the end of life for patients with ICDs in whom once life- prolonging shocks may only cause unnecessary morbid- ity and distress to both patients and loved ones. Recommendation-Specific Supportive Text 1. Current evidence suggests that many patients are unaware of the possibility that their ICD can be deactivated without surgery.S14-1 S14-3 During deci- sion-making, clinicians do not routinely inform patients about ICD deactivation.S14-4 Clinicians even disagree on whether discussions of deac- tivation should occur when patients are making a decision about an ICD-related procedure.S14-5 As a result, patients often do not include wishes about deactivation in advance care planning Consequently, surrogates usually make decisions about ICD deactivation without any prior discussions with the patient.S14-6 In hypo- thetical scenarios, patients with ICDs were able to identify scenarios in which they might choose to deactivate their ICD.S14-1,S14-7 This discussion can occur at any time, but it is particularly important to have it at the time of initial ICD implantation, at the time of reimplantation, and during prepa- ration of advance care plans. 2. 