Deactivating an Implantable Defibrillator in Home Hospice: An Ethical Case Analysis in Advanced Heart Failure
[Author Name]
College of Nursing and Health Care Professions, Grand Canyon University
PHI-413V: Ethical and Spiritual Decision Making in Health Care
Topic 3 Assignment
[Instructor Name]
August 11, 2026
Composite case written as a model document. No real patient, family, clinician or hospice program is described.
The Case and the Question It Raises
The patient described here is a composite built for teaching. Mrs. A is a 71-year-old retired postal clerk living at home with her adult son. She carries stage D heart failure with a left ventricular ejection fraction of 18 percent and symptoms at rest that place her in New York Heart Association class IV. An implantable cardioverter defibrillator was placed six years ago after a survived cardiac arrest. She has been admitted three times in the past nine months for fluid overload, has lost 11 kg since January, and elected home hospice 12 days ago after her cardiologist told her that continued inotropic support would not lengthen her life. In the past 60 days the device has delivered seven shocks, three of them in a single night.
On the fourth home visit Mrs. A asked the hospice nurse to have the shocks turned off. In her own words: 'I am not trying to die faster. I am tired of being kicked by a horse in my sleep.' A capacity evaluation the same day found her alert and oriented and able to state the choice, her reasons, the expected consequence of deactivation and the expected consequence of leaving the device active. Her PHQ-9 score was 4 out of 27, which gives no reason to think a treatable mood disorder is driving the request. Her advance directive, signed 14 months ago, names comfort as her priority and her son as alternate decision maker.
Her son objects. He believes that turning the device off is the same as ending her life, and he has told the team that his mother is a woman of faith who should not 'give up on what God can still do.' The ethical question is therefore narrow and has to be stated precisely: may a clinician honor a capacitated patient's request to withdraw an already implanted therapy when the person who loves her most reads that withdrawal as killing? The question is not whether her life still has value, which no one at the table disputes, and not whether anyone may hasten her death, which no one has asked for.
The Four Principles Applied to This Case
Principlism supplies four obligations that are weighed against each other rather than ranked in advance, and the first is respect for autonomy (Beauchamp & Childress, 2019). Mrs. A meets every element of decisional capacity, so her refusal of continued defibrillation carries the authority of any other informed refusal, including refusal of dialysis or of a feeding tube. Two points settle much of the argument. A patient may refuse a treatment that is already running, and the moral weight of withdrawing a therapy is not different from the weight of never starting it. Deactivating a defibrillator permits an arrhythmia the disease itself produces to end a life the disease is already ending, and it introduces no new lethal agent (Lampert et al., 2010).
Beneficence and nonmaleficence turn on burden weighed against benefit, and both sides of that ledger have to be filled in with this patient's numbers rather than with general claims about defibrillators. What the device offers is protection from sudden arrhythmic death. In stage D disease that protection buys very little survival; it mostly exchanges a rapid arrhythmic death for a slower death from pump failure, and it does so at a price her chart already records: seven shocks in 60 days, three in one night, and a fear of sleep that her nurse documented before anyone raised deactivation. Shocks delivered during her dying would add pain without altering what the pain is bought for.
Justice asks whether this patient is being treated as any other patient in her position would be treated. The answer must not turn on her family's religion, her coverage, or the cost of a home visit by the device technician, and the same process would be offered to a patient who was Muslim, Jewish, humanist or indifferent to religion altogether. Justice also protects clinicians: a nurse or physician who cannot participate in deactivation may step aside, provided the patient is not abandoned and care is handed over without delay (American Nurses Association, 2015). Weighing the four together, autonomy and nonmaleficence point the same way, and neither beneficence nor justice pulls against them.
Worldview, Spiritual Care, and the Family's Objection
A Christian worldview reads this case through the conviction that a human life is a gift held in trust rather than property to be disposed of, which grounds a strong duty to care for the sick and a refusal to aim at anyone's death. That same tradition has long held that the duty to preserve life does not require every available means, and it distinguishes ordinary care, which offers reasonable hope of benefit, from extraordinary means whose burden outweighs what they deliver. Read through that lens, declining a device that produces pain without changing the outcome is acceptance rather than despair. These are theological and moral claims, reported as the tradition states them, and they settle no clinical fact.
The son's objection deserved an answer inside his own frame of reference rather than a policy quotation. The chaplain took a spiritual history with the patient first, following the prompts of faith, importance, community and address in care (Puchalski & Romer, 2000). Mrs. A said that she had prayed about the device for two months, that she was not ending anything, and that she wanted to die in her own bed rather than in a hallway. At a family meeting the team set burden and benefit side by side, named what deactivation would do and what it would not do, and let the son hear his mother say in her own voice what she wanted for herself.
Spiritual care belongs in the clinical record rather than in the category of optional courtesy, since a whole-person model treats the spiritual dimension as one more domain in which a dying person can suffer (Sulmasy, 2002; National Coalition for Hospice and Palliative Care, 2018). The obligation runs the same way for every patient. A nurse elicits the beliefs the patient actually holds, documents them, and builds the plan around them; a nurse does not supply beliefs, correct them, or use a bedside relationship to move a patient toward the nurse's own convictions. Had Mrs. A held no religious commitments at all, the same conversation would still have been owed to her.
The Decision, the Alternatives, and What Makes It Defensible
The decision was to honor the request. Shock therapy was deactivated at the bedside by the manufacturer's field representative under a written physician order, with a magnet kept in the home as a backup; anti-tachycardia pacing was turned off with it, while bradycardia pacing was left on because it burdens her with nothing and keeps her rate above 50 while she is awake. The comfort plan was written the same day: scheduled and as-needed opioid for dyspnea, an anxiolytic for the fear the shocks had built, an order against resuscitation consistent with her hospice election, and a line in the record telling any responding crew that the device will not shock.
Three alternatives were considered and rejected on the record. Leaving the device active and adding an antiarrhythmic drug would have reduced shocks at the cost of new side effects, without changing the trajectory of stage D disease. Deferring the decision until she was closer to death would itself have been a decision, since the previous 60 days had already produced seven shocks and devices fire most in the final hours of dying. Overriding her in favor of her son would have replaced the values of a patient who has capacity with the values of a surrogate whose authority has not begun, which the Code of Ethics for Nurses forbids and which no principle in this analysis supports.
What makes the decision defensible is not the outcome but the record behind it. Capacity was documented by criterion rather than asserted. The burden of the therapy was counted before it was called a burden. The family's religious objection was engaged by a chaplain and answered in the tradition's own terms rather than treated as an obstacle, and the son was offered bereavement support that began before his mother died. Mrs. A died at home 19 days later with her son present and no shock delivered. Another patient weighing the same facts and holding different beliefs could have chosen to keep the device active, and that choice would have deserved the same respect.
References
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/coe-view-only
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
Lampert, R., Hayes, D. L., Annas, G. J., Farley, M. A., Goldstein, N. E., Hamilton, R. M., Kay, G. N., Kramer, D. B., Mueller, P. S., Padeletti, L., Pozuelo, L., Schoenfeld, M. H., Vardas, P. E., Wiegand, D. L., & Zellner, R. (2010). HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm, 7(7), 1008-1026.
National Coalition for Hospice and Palliative Care. (2018). Clinical practice guidelines for quality palliative care (4th ed.). https://www.nationalcoalitionhpc.org/ncp
Puchalski, C., & Romer, A. L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3(1), 129-137.
Sulmasy, D. P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, 42(Suppl. 3), 24-33.
How this PHI 413V Topic 3 example is structured
In many sections this topic asks for a written case analysis that carries a named ethical framework into a decision; your classroom's instructions and rubric decide the exact form, so read the assignment page before you use this PHI-413V Topic 3 example as a shape. The paper is ordered the way an ethics consultation actually runs. The case comes first, with the medical facts and the patient's own words, because no principle can be applied to a case the reader does not yet know. The four principles come second, each weighed against those same facts rather than listed. Worldview and spiritual care come third, where the family's objection is answered and the patient's own beliefs are heard as hers. The decision comes last, with the alternatives that were rejected and the reasons they were.
PHI-413V Topic 3 questions, answered
What does PHI-413V Topic 3 usually ask for?
In many sections this topic asks for a written case analysis that applies a named ethical framework to a health care situation and reaches a defended decision. Some classrooms pair it with discussion questions on the same case. The exact requirements belong to your classroom, so read the assignment page and rubric posted with the topic before you set your headings.
How do I write about a Christian worldview without preaching?
State the tradition's reasoning accurately, attribute it, and mark it as a moral or theological claim rather than a clinical fact. Then let the patient's own beliefs govern the plan, and show that a patient of another faith or none would receive the same care. Analysis of a worldview is the academic work; persuading a reader toward one is not.
Can I submit this paper as my own work?
No. This is an original model document written by our desk to show what a finished ethical case analysis looks like. It is not a student submission and carries no grade. Use it to see how facts, principles, worldview and decision hold together, then write your own case in your own words. Copying any part of it is plagiarism.
Write yours, or have the desk draft it
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